Welcome to IMC Please fill out this form as completely as you can. If you have any questions we'll be glad to assist you. We look forward to working with you in maintaining your health. Patient Information Name _ (First Name) (Last Name) Address City/State/Zip Home Phone Sex: 0- M Cell # ~ F Age _ Work # .DOB _ ,~ Single ~ Married ~ Divorced ~ Widowed Patient Employed By Occupation. Email Address _ Referred By NOTIFY IN CASE OF EMERGENCYIRELEASE OF LIABILITY: _ (Nanle and phone # of 2 people) 1. Phone# _ 2. Phone# _ Reason For Visit Your reason for this visit: _ Have you ever seen a physician for this problem? If yes, when? _ Physician's Name _ Describe your pain and location: Date symptoms began: _ Have you had similar conditions in the past? Activities that are difficult/painful to perform: ~ Sitting Type of pain: ~ Sharp ~ Tingling L1 Dull ~ Throbbing ~ Cramping ~ Walking ~ Aching ~ Stiffness ~ Bending ~ Burning ~ Swelling Other: ~-- ~ Lifting ~ Numbness _ Please list any serious injuries or surgeries you have had in the last 10 years: Description Falls _ Broken Bones _ Dislocations _ Surgeries _ Other injuries: Date _ Medical Conditions t:,.Heart Attack/Stroke t:,.Congenital Heart Defect t:,.Alcohol/Drug Abuse t:,.Fainting/Seizures/Epilepsy t:,.Shingles t:,.Psychiatric Problems t:,.Difficulty Breathing t:,.Anemia t:,.Arthritis t:,.Frequent Neck Pain t:,.Jaw Pain t:,.Wrist Pain t:,.Shoulder Pain t:,.Arm Pain t:,.Leg Pain t:,.Low Back Problems t:,.Ringing in ears t:,.Frequent Headaches t:,.Diabetes/Tuberculosis t:,.Dizziness t:,.Emphysema/Glaucoma t:,.Kidney Problems t:,.Artificial Bones/Joints t:,.Severe/Frequent Earaches t:,.Ulcer/Colitis t:,.Gout t:,.Numbness t:,.Tingling t:,.Muscle Spasms t:,.Hepatitis t:,.Cancer t:,.HIV/AIDS Personal Habits HEAVY MODERATE LIGHT NONE Alcohol Coffee Tobacco Drugs Exercise Sleep Appetite Authorization I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the Healthcare Provider to help determine appropriate and healthful treatment. If there is any change in medical status, I will inform the Healthcare Provider. Initial. -'I have read the Privacy Practices Notice. IMC will call and remind me of my appointments. NOT like a reminder call, I will inform you in writing. Initial -'- I understand that [Me has a 24-hour cancellation and I may be billed for any missed appointment. Signed: Date: Payment is due in full at time of treatment. If I would policy _ IMC, LLC 315 Magnolia Avenue Fairhope, AL 36532 INFORMED CONSENT As a patient of IMC, I give the physicians and staff the authority to treat me in accordance with tests, diagnosis and analysis. The clinical procedures listed below are, in most cases, beneficial and rarely cause problems or injury. In these rare cases, problem or injury may be due to underlying physical defects, deformities, illnesses and/or pathologies. As a patient, I understand it is my responsibility to make such conditions, which would not otherwise be discovered or obvious, known to the physicians prior to treatment. I understand that by being accepted as a patient, I am authorizing IMC to proceed with any treatment that may be deemed necessary. I also understand that I have the right to have any questions about treatments or procedures fully explained to me. Modalities that may be used in your treatment include: Acupuncture Electric Stimulation Therapeutic MassagelExercise Chiropractic Cold Laser Therapy Hot/Cold Packs LET US KNOW WHAT YOUR PAIN LEVEL IS What is your current level of pain on a scale of 0 (no pain) to 10 (extreme pain)? When is pain worst? !J.. Morning !J.. Afternoon !J.. Evening _ !J.. Bedtime Do any medications help your pain? _ Other treatments you've had for pain? _ I have read and understand the Informed Consent for my healthcare needs. Print Patient Name Patient Signature Date IMe MED LIST Please list all medications/vitamins· Name of Medication Date Informed . Name of Medication Date Informed