Chiropractic and Physical Therapy of Florida, LLCW. Martin Underwood, D.C. and Youngsoo Suh, R.P.T.

2901 W St. Isabel Street, Suite A2Tampa, Florida 33607

Office 813-644-7017 Fax 813-644-7018chiroptofflorida@gmail.com

WELCOMEThe doctor and staff welcome you and want to provide you with the best possible care. We will conduct a thorough history and physical examination to decided if we can assist you. If we do not believe your condition will respond to chiropractic care, we will not accept you as a patient, but will refer you to another health care provider, if appropriate.

ACCEPTANCE AS A PATIENTI understand and agree that the doctor has the right to refuse and accept me as a patient at any time before treatment begins. The taking of a history and the conducting of a physical examination are not considered treatment, but are part of the process of gathering information so that the doctor can determine whether to accept me as a patient.

INSURANCE (PPO-HCH PATIENTS)This office will process your insurance forms as a courtesy to you. We will do our utmost to provide sufficient information to your carrier to obtain payment for your treatment. We have found that in some instances insurance companies may deny or reduce payment despite our best efforts to demonstrate the necessity for care. It is my understanding that my insurance carrier may have limitations that apply to my chiropractic treatment and the number of visits my policy allows. I understand that my insurance policy is a contract between the insurance carrier and myself. I agree to assume all financial responsibility once these limitations have been satisfied and no further insurance coverage is available. I understand that services are payable when rendered, unless previous financial arrangements have been arranged.

EXPLANATION OF COVERED SERVICES FOR PPO-HCHC PATIENTSAcupuncture, orthotics, neuromuscular massage therapy, stress relief massage, rehabilitative exercises, fitness memberships, as well as maintenance/preventative chiropractic treatment, are usually considered outside covered insurance benefits and are, therefore, the patient’s financial responsibility.

SPECIAL NOTESome insurance companies have excluded the therapy modalities (EMS, Ultrasound, Infrared heat, Traction, etc.). While the doctor may recommend this treatment to you as medically necessary and beneficial for you particular condition, please understand that it is your financial responsibility.

I HAVE READ THE FOREGOING AND UNDERSTAND IT

Signature _____________________________________ Date ________________________

PATIENT QUESTIONNAIRE Thank you for taking the time to answer this questionnaire. Please bring it with you to your appointment. It will be reviewed with you at that time.PERSONAL INFORMATION: (Confidential)

Name: ______________________________ Age: ______ Date of Birth: __________________

Address: _____________________________ SS#: _______________________ Sex: M F

City: ______________________ State: ________________ Zip Code: ___________________

Home Phone: ( ) __________________ Alternate Phone: ( ) ____________________

Employer: _______________________________ Work Phone: ( ) ____________________

Personal Physician: _______________________ Pharmacy Name: ______________________

Emergency Contact Name: _________________________ Phone: ______________________

INSURANCE: ________________________________ ID#: ____________________________

Address: _______________________________________ Phone: _______________________

Policy holder: _________________________________________ D.O.B. _________________

PAIN HISTORY:

Location: Use the figures below to shade in the area where you have pain. If your pain moves around, put an ‘X’ where it starts and draw an arrow to where it spreads.

For office use only

Ht: ___________

Wt: ___________

B.P. ___________

Pulse: ___________

SPO: ____________

Temp: ____________

Chief Complaint:Where is/are your main area(s) of pain? (Describe, or check below): _____________________

Duration:When did you current pain problem begin? __________________________________________

Onset:How did your pain problem first start? ( )Job injury ( )Sports Injury ( )Car accident ( )Disease ( )Cancer ( )Unknown ( )Other:_______________________________

Frequency: How often do you have this pain? ( )Constantly ( )Daily ( )Weekly ( )Monthly At what time of the day is the pain the worst? ( )Morning ( )Afternoon ( )Evening ( )NightAt what time of the day is the pain the least? ( )Morning ( )Afternoon ( )Evening ( )Night

Severity:Rate the severity of your pain right now by circling the corresponding number below.

1 2 3 4 5 6 7 8 9 10

Rate the severity of your pain on average by circling the corresponding number below.

1 2 3 4 5 6 7 8 9 10

Character:Describe in your own words what the pain is like. (i.e. sharp, dull, burning, etc.) _____________

____________________________________________________________________________

Associated signs and symptoms: Are you experiencing any of the following?

Aggravating or Alleviating factors:What activities or factors improve or worsen your pain? (Check all that apply)

Head Upper back Legs R L

Neck Lower back Arms R L

Chest Groin Hands R L

Abdomen Buttocks Feet R L

Yes No Location or Description

Muscle Weakness

Numbness or tingling

Bladder of bowel disfunction

Rash

Fever

Visual disturbance

Other:

Effects on activities of daily living:Are there areas of your live that have been adversely affected by your pain problem? (Check below all those that apply, and please describe)

( ) Sleep _______________________________________( ) Appetite ________________________________________( ) Relationships ________________________________________( ) Work ________________________________________( ) Finances ________________________________________( ) Physical Activity ________________________________________( ) Use of Alcohol or recreational drugs _______________________________________( ) Other _______________________________________ Treatments: What treatments have you received for your pain in the past? (check accordingly)

Activity Worsens Relieves No change

Activity Worsens Relieves No change

Exercise Bright Lights

Climbing Stairs Cold

Walking Heat

Standing Noise

Sitting/Driving Emotion

Lifting Weather Change

Cough/Sneeze Rest

Lying down Touch

Eating Other:

Treatment Helpful Not Helpful Comments

Surgery

Nerve Block

Steroid injection

Trigger point injection

Acupuncture

TENS unit

Heat/Ice treatment

Biofeedback

Hypnosis

Relaxation training

Diagnostic Testing: Have you had any of the following performed on you in the last 24 months?

Past Medical History:Please check any of the medical problems you have had or currently have:( ) Diabetes________________________________ ( ) Arthritis ________________________( ) Cancer_________________________________ ( )Ulcer__________________________( ) Heart problems__________________________ ( ) Kidney problems________________( ) Respiratory problems______________________ ( ) Bleeding problems_______________( ) Infectious disease_________________________ ( ) Seizures______________________( ) High blood pressure_______________________ ( ) Neurologic disease______________( ) Migraines________________________________ ( ) Head injury____________________( ) Other____________________________________________________________________

Past surgical history:

Allergies: Please list all medication allergies below

Counseling

Traction

Chiropractic treatment

Occupational therapy

Physical therapy

Other (explain)

Test Date Facility where test was done Results

X-ray film

CT scan

MRI

Laboratory

EMG

Nerve conduction

Discogram

Myelogram

Other:

Date Procedure/Illness Date Procedure/Illness

Have you ever had a reaction to Iodine, Shellfish, or contrast dye?

( ) Yes ( ) No (if so, please explain)_____________________________________

Medications: Please list all of your current medication, both prescription and over the counter

Please list any other pain medication you have used in the past:

Have you been on any blood thinners recently? (i.e. PLAVIX, coumadin, warfarin, heparin, or aspirin) ( ) No ( ) Yes (if so, please list)___________________________________

Medication Reaction

Medication Amount Times per day Effectiveness

Medication Amount Times per day Effectiveness

SOCIAL HISTORY: Marital status:What is your current marital status?( ) Single ( ) Living with significant other ( ) Married ( ) Divorced ( ) Widowed

Has your marital status changed since your pain problem began? ( ) Yes ( ) No

How many children are living with you? _________________

Education:What is the highest level of education you have received? ______________________________

Employment:Are you currently working? ( ) Yes ( ) No ( ) Retired Occupation ____________________

Is the same occupation you had before you pain problem started? ( ) Yes ( ) No

If you are not working, has pain caused you to stop working? ( ) Yes ( ) No

If you are not working, what was your occupation before your pain started? ________________

Does your spouse work? ( ) Yes ( ) No Spouse’s occupation_________________________

Are you being treated under worker’s compensation? ( ) Yes ( ) No

Are you currently receiving disability benefits? ( ) Yes ( ) No

Habits: Do you currently smoke? ( ) No ( ) Yes How many packs a day?_______ # of years_____

Do you drink alcoholic beverages? ( ) No ( ) Yes How many drinks per day?____________

Do you use any recreational or “street” drugs? ( ) No ( ) Yes (if so list)_________________

Do you drink beverages with caffeine? ( ) No ( ) Yes how many serving a day?__________

FAMILY HISTORYPlease check below if you have a family history of any of the following:

Brother Sister Mother Father Aunt Uncle Grandmother Grandfather

Diabetes

Cancer

Heart disease

Stroke

Hypertension

SYSTEMS REVIEW:Please check below if you are experiencing or have experienced any of the following:

General: Genitourinary:( ) Weight loss/gain_________ ( ) Trouble urinating( ) Chills ( ) Frequent urination ( ) Bloody urine

Ear, Nose, and throat: Women:( ) Sinus pressure/drainage ( ) vaginal bleeding( ) Sore throat ( ) vaginal discharge ( ) Difficulty hearing Could you be pregnant? ( ) Yes ( ) No( ) Vision problems Are you trying to become pregnant? Y N Last normal menstrual period __________

Pulmonary and Cardiovascular: Neurological and psychological:( ) Chest pain ( ) Headache ( ) Cough ( ) Blackout( ) Trouble breathing ( ) Confusion ( ) Depression

Gastrointestinal:( ) Abdominal pain( ) Nausea/vomiting ( ) Diarrhea( ) Constipation( ) Black/Bloody stools

Patient Signature: ___________________________________________________________

Migraines

Chronic pain

Anesthetic Problems

Substance abuse

Other:

INFORMED CONSENT FOR CHIROPRACTIC TREATMENT TO THE PATIENT: You have a right to be informed about your condition, the recommended chiropractic treatment, and the potential risks involved with the recommended treatment. This information will assist you in making an informed decision whether or not to have the treatment. This information is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or refuse to give your consent to treatment.

I request and consent to chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic X-rays. The chiropractic treatment may be performed by the Doctor of Chiropractic named below and/or other licensed Doctors of Chiropractic working at this clinic or office. Chiropractic treatment may also be performed by a Doctor of Chiropractic who is serving as a backup for the Doctor of Chiropractic named below

I have had the opportunity to discuss with the Doctor of Chiropractic named below, my diagnosis, the nature and purpose of my chiropractic treatment, the risks and benefits of my chiropractic treatment, alternatives to my chiropractic treatment, and the risks and benefits of alternative treatment, including no treatment at all.

I understand that, there are some risks to chiropractic treatment including, but not limited to:__ Broken bones __ increased symptoms and pain__ Dislocations __ No improvement of symptoms or pain__ Sprains/strains __ Infection (acupuncture)__ Burns or frostbite (physical therapy) __ Punctured lung (acupuncture)__ Worsening/aggravation of spinal conditions __ Other ___________________________

In rare cases there have been reported complications of arterial dissections n (stroke) when a patient receives a cervical adjustment. The complications reported can include temporary minor dizziness, nausea, paralysis, vision loss, locked in syndrome (complete paralysis of voluntary muscles in all parts of the body except for those that control eye movement), and death.

I do not expect the doctor to be able to anticipate and explain all risks and complications. I also understand that no guarantees or promises have been made to me concerning the results expected from the treatment.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions. All of my questions have been answered to my satisfaction. By signing below, I consent to the treatment plan. I intend this consent form to cover the entire course of treatment for my current condition.To be completed by the patient: To be completed by the patient’s representative, if

necessary, e.g., if the patient is a minor or __________________________ physically or legally incapacitated:print name __________________________________________________________________ print name of patientsignature of patient ________________________________________ print name of patient’s representative __________________________ ________________________________________date signed signature of patient’s representative as: ______________________________________ relationship or authority of patient’s representative To be completed by doctor or staff _________________________________________ date signed

__________________________ _______________ ____________________ _____________witness to patient’s signature date translated by date

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I was provided a copy of the Notice of Privacy practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years.

_______________________________ ______________________________Patient name (please print) Date

_______________________________________________Parent, guardian, or legal representative

__________________________________________Signature

W. Martin Underwood, D.C.Board Certified in Chiropractic Medicine

Certified in Physiotherapy and Acupuncture

HIPAA Notice of Privacy PracticesTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

IT CAREFULLY

This Notice of Privacy Practices describes how we may use and sic lose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

1. Uses and Disclosures of Protected Health InformationYour protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of you health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physicians practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to Concorde institute students that see patients in our office. In addiction, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may ask call you by

name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information as necessary, to contact you to remind you of your appointment.We may use of disclose your protected health information in the following situation without your authorization, These situations include: as Required By Law, Public Health issues as required by law, Communicable diseases; Health Oversight; Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Law Enforcement; Coroners, Funeral Director, and Organ Donation; Research; Criminal Activity; Military Activity and National Security; Workers’ Compensation; inmates; Required Uses and Disclosures; Under the law, we must make a disclosures to you and when required by the secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirement of Section 164.500.

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO ANY ISSUE DISCUSSED ABOVE REGARDING ‘HIPAA Notice of Privacy Practices”

Date: _________________________ Time: ____________________________ A.M./ P.M.

Signature: _________________________________________________(Patient/parent/legal guardian/legal representative)If signed by other than patient, indicate relationship: ____________________________

W. Martin Underwood, D.C.Board Certified in Chiropractic Medicine

Certified in Physiotherapy and Acupuncture

CHIROPRACTIC & PHYSICAL THERAPY OF FL2901 W. St. Isabel Street, Suite A-2

Tampa, Florida 33607Office 813 - 644 - 7017 Fax 813 - 644 - 7018

Office Visits & Physical Therapy Compliance

As a patient of Chiropractic and Physical Therapy of Florida certain policies and expectations are in place to manage your care in our facility efficiently.

1. If you cannot attend a visit with the doctor or physical therapy appointment, please notify the office 24 hours in advance. You must speak with someone in the office, do not leave a message on the answering machine. If you do not show or do not contact us to reschedule the appointment, a charge will be issued for the missed appointment.

2. Three no call / no show appointments in a row will result in a notification sent to your primary care physician to have you reassigned to another facility for physical therapy.

3. FAILING TO KEEP INITIAL OR FOLLOW-UP APPOINTMENT AND/OR PHYSICAL THERAPY, IS CONSIDERED NON-COMPLIANCE WITH YOUR MEDICAL CARE, WHICH MAY AFFECT YOUR OUTCOME.

4. Follow-up appointments and physical therapy are scheduled before you leave the clinic at each visit.

Patient’s signature______________________________

Office Witness__________________________________

Date__________________________________________