COUNTY LINE CHIROPRACTIC CENTERS
Accident Pain? We Can Help!
Five convenient locations in Dade,
Broward, and Palm Beach Counties.
Call Toll Free:1-800-811-1231
2000 CHIROELITE.ORG
Confidential Patient Information
Date __________________
First Name: ________________________ Last Name: __________________________ Initial ____
Major Complaint Information
What is your major complaint (s)? __________________________________________________________
___________________________________________________________________________________________________
When did this symptom(s) begin?__________________________________________________________
Using the symbols provided in the Pain Index, mark the areas on the illustrations below where you are experiencing pain,
followed by a number from 1 to 10 indicating the extent of the pain. (1 being minor, 10 being severe)
Pain Index
B Burning
S Sharp/Stabbing
RIGHT LEFT RIGHT
For example: if you are experiencing moderately
severe burning pain in back of your neck, you
should note a B8 on the neck of the illustration.
If this is an injury, describe what happened:
__________________________________________
__________________________________________
__________________________________________
__________________________________________
On a scale of 1-10, how do you feel now? (1 being best, 10 being the worst)
1 2 3 4 5 6 7 8 9 10
Have you experienced these symptoms before? Yes No When? __________________________
These symptoms developed from? Auto Accident Work-Related Other: ______________
Have you reported this to your: insurance company Yes No employer Yes No
What aggravates this condition? __________________________________________________________
What decreases the symptoms/pain? ______________________________________________________
Have you seen a doctor for this condition? Yes No Doctors Name: ________________________
Date consulted: __________________ Diagnosis: ____________________________________________
Does this condition interfere with your sleep? Yes No If so, how many times do you wake up in
pain per night? ________________________________________________________________________
In what position do you sleep? Back Side Stomach
Do you sleep with a pillow? Yes No How many? ______________________________________
Does heat affect the pain? Yes No If so, how? ________________________________________
Does cold affect the pain? Yes No If so, how? ________________________________________
Do you wear a heel lift? Yes No If so, which side? Right Left
Does it cause pain to cough, grunt or sneeze? Yes No If so, where? ________________________
 Check those activities below during which you experience difficulty or pain:
___ Lying on back ___ Getting in/out of car ___ Sleeping ___ Stooping ___ Standing for periods
___ Lying on side with ___ Gripping ___ Pushing ___ Sitting over one hour
knees bent ___ Climbing ___ Pulling ___ Bending forward ___ Sneezing
___ Turning over in bed ___ Dressing self ___ Reaching ___ Bending backward ___ Coughing
___ Lying flat on stomach ___ Sexual activity ___ Kneeling ___ Walking ___ Other: _____________

Fill out the next three sections as they apply to you

Headaches
Do you have a family history of headaches? Yes No Do you get headaches? Yes No Frequency ________________
Do you experience the following along with your headaches: Pain or cracking in your jaw? Yes No
Abnormal blood pressure? Yes No High Low Nausea, Vomiting or Visual disturbances? Yes No
When was your last eye exam by a doctor? 1-6 months 6-12 months 1-2 years over 2 years Results:__________

Lower Back Pain

Do you ever experience ripping or tearing sensations in your back? Yes No If so, where? ____________________________
Does pain radiate to the abdomen? Yes No
Do you ever have impairment of bowel or urinary function? Yes No Explain: ____________________________________

Neck Pain
If you have a neck injury, does it effect: (Check all that apply) hearing vision balance cause ringing in your ears
Do you hear grating sounds? Yes No Do you feel pressure or pain behind your eyes? Yes No
Do you feel ripping or tearing? Yes No Where? ____________________________________________________________
Do you have difficulty lifting or turning your head? Yes No If so, in which direction? Right Left Up Down

If female, are you pregnant? Yes No Not Sure If yes, what is your due date:______________________________________
List all medications you are taking now, including over the counter medication.____________________________________________
_____________________________________________________________________________________________________________
Are you allergic to any medications: Yes No Not Sure Please list: ____________________________________________
_____________________________________________________________________________________________________________
Have you ever had any surgeries or hospitalizations? Yes No Please List:
Type of Hospitalization/Surgery: Date: Type of Hospitalization/Surgery: Date:
______________________________________ ______________ ____________________________________ ____________
______________________________________ ______________ ____________________________________ ____________
Have you been x-rayed in the last 12 months? Yes No When?: __________________________________________________
Have you ever been seen by a chiropractor before? Yes No Please List:
Name of chiropractor: Dates: Name of chiropractor: Dates:
______________________________________ ______________ ____________________________________ ____________
Do you have a family physician? Yes No Name of physician: __________________________ Phone: ________________
Address: ____________________________________________________________________________________________________
City/State/Zip: ______________________________________________________________________________________________
 Additional Complaints
Please check all additional complaints that you have at this time:
Headache Neck Stiffness Loss of Consciousness Cold Feet Arthritis
Loss of Concentration Neck Motion Restricted Irritable Jaw Pain HIV (Aids)
Eyes Sensitive to Light Upper Back Pain/Stiffness Anxiety Cancer Other (Please List)
Memory Loss Mid Back Pain/Stiffness Depression Hypertension ______________________
Heavy Feeling of Head Lower Back Pain/Stiffness Insomnia Diabetes ______________________
Dizziness Right/Left Shoulder Pain Fatigue Hepatitis ______________________
Ringing in Ears Right/Left Arm Pain Flushed Face Convulsions
Loss of Balance Right/Left Leg Pain Excess Perspiration Allergies (Please List)
Please Specify Location:
Loss of Smell Pins & Needles Arms/Legs Digestive Trouble ________________________ Numbness __________
Loss of Taste Vision Problems Nausea ________________________ Swelling ____________
Pain Behind Eyes Sinus Trouble Vomiting ________________________ Cuts________________
Fainting Nervousness Diarrhea ________________________ Bleeding ____________
Palpitation Chest Pain Constipation Anemia Broken Bones ________
Neck Pain Shortness of breath Cold Hands Heart Disease Bruising ____________

Do you have, or have you ever had, any diseases or medical problems not listed? Yes No If so, please list: ________________
_____________________________________________________________________________________________________________
Any additional information you would like the doctor to know about before beginning care at County Line Chiropractic
Beach Boulevard Center? ____
Chiropractic?
_____________________________________________________________________________________________________________

Emergency Contact
Name: ____________________________________________________________________________ Relation:________________
Home Phone: __________________________________________ Work Phone:________________________________________
Address: ____________________________________________________________________________________________________
City/State/Zip: ______________________________________________________________________________________________

Insurance Information
Insurance Company:____________________________________________________________ Phone # ____________________
Address: ____________________________________________________________________________________________________
City/State/Zip: ______________________________________________________________________________________________
Insureds Name: ____________________________ Insureds SS# __________________________ Group # ______________

Insureds Birth Date: ________________________ Insureds Employer ______________________________________________

Personal Information
Address: ____________________________________________________________________________________________________
City/State/Zip: ______________________________________________________________________________________________
Home Phone: __________________________________________ Work Phone:________________________________________
Mobile Phone: ______________________ Pager: __________________________ Email: ____________________________
Email:__________________________________________________________________
Social Security #:____________________________________ Birth Date: __________________ Age: ______ Sex M F
Drivers License # ____________________________________________________________________________________________
Marital Status: S M D W Spouses Name: ________________________________________ # of Children: ______
Occupation: ________________________________ Employers Name: ______________________________________________
Work Address: ______________________________________________________________________________________________
City/State/Zip: ______________________________________________________________________________________________
How were you referred to County Line Chiropractic
Beach Boulevard Center?____________________________________________________________
Chiropractic?
Do you have an Attorney? Yes No Name: __________________________________________________________________
Phone #: __________________________ Address:________________________________________________________________
 Informed Consent
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. I clearly
understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also under-
stand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and
payable. I will be responsible for any costs of collection, attorneys fees or court costs required to collect my bill.
I hereby authorize physicians and staff at County Line Chiropractic
Beach Boulevard Center to treat my condition as deemed appropriate. It is understood
Chiropractic
and agreed the amount paid the doctor for X-rays, is for examination only and the X-ray negatives will remain the property of this office,
being on file where they may be seen at any time. The doctor will not be held responsible for any pre-existing medically diagnosed condi-
tions.
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any staff member of County
Beach Line
Chiropractic
Boulevard Center responsible for any errors or omissions that I may have made in the completion of this form.
Chiropractic
Chiropractic, as well as many other types of health care, is associated with potential risks in the delivery of treatment. Therefore it is neces-
sary to inform the patient of such risks prior to initiating care. While chiropractic treatment is remarkably safe, you need to be informed
about the potential risks related to your care to allow you to be fully informed before consenting to treatment.
Chiropractic is a system of health care delivery and therefore, as with any health care delivery system, we cannot promise a cure for any
symptom, condition or disease as a result of treatment in this office. An attempt to provide you with the very best care is our goal and if the
results are not acceptable, we will refer you to another provider who we feel can further assist you.
Specific Risk Possibilities Associated with Chiropractic Care.
Soreness- Chiropractic adjustments and physical therapy procedures are sometimes accompanied by post treatment soreness. This is a nor-
mal and acceptable accompanying response to chiropractic care and physical therapy. While it is not generally dangerous, please advise your
doctor if you experience soreness or discomfort.
Soft Tissue Injury- Occasionally chiropractic treatment may aggravate a disc injury, or cause other minor joint, ligament, tendon or other
soft tissue injury.
Rib Injury- Manual adjustments to the thoracic spine, in rare cases, may cause rib injury or fracture. Precautions such as pre-adjustment x-
rays are taken for cases considered at risk. Treatment is performed carefully to minimize such risk.
Physical Therapy Burns- Heat generated by physical therapy modalities may cause minor burns to the skin. These are rare, but if it occurs
you should report it to your doctor, or a staff member at County Line Chiropractic
Beach Boulevard Center.
Chiropractic.
Stroke- Stroke is the most serious complication of chiropractic treatment. The most recent studies ( Journal of the CAA, Vol. 37 No. 2, June,
1993) estimate that the incidence of this type of stroke is 1 in every 3 million upper cervical adjustments.
Other Problems- There are occasionally other types of side effects associated with chiropractic care. While these are rare, they should be
reported to your doctor promptly.
If you have any questions concerning this form or the above statements, please ask your doctor.
Having carefully read the above, I hereby give my informed consent to have chiropractic treatment administered.

_____________________________________________________________________________________________________________
Patient Signature: Date

_____________________________________________________________________________________________________________
Parent/Legal Guardian Signature: Date

Seasonal Address Information

If you reside at a second address during part of the year, please provide the information below:
Second Address: ______________________________________________________________________________________________
City/State/Zip: ______________________________________________________________________________________________
Phone: ________________________________________________
Check months at this address:

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
 BEACH BOULEVARD CHIROPRACTIC, LLC

POWER OF ATTORNEY AND MEDICAL RELEASE

POWER OF ATTORNEY TO ENDORSE CHECKS AND/OR TO SIGN ANY PIECE OF PAPER WHICH WILL
ENHANCE OR EXPEDITE PAYMENT TO PROVIDER FOR SERVICES RENDERED, INCLUDING BUT NOT
LIMITED TO A RELEASE OF MEDICAL RECORDS AND ASSIGNMENT OF BENEFITS/AUTHORIZATION TO
PAY.

Know by all these present that: The undersigned has made, constituted and appointed, and by these presents does hereby
make, constitute and appoint BEACH BOULEVARD CHIROPRACTIC, LLC, and any of its duly authorized agents and
employees as and to be the undersigned's true and lawful attorney for and in the undersigned's name, place and stead to
endorse and all checks, drafts of money order which are made payable to the undersigned alone or to the undersigned and
the said BEACH BOULEVARD CHIROPRACTIC, LLC, which checks, drafts or money orders are made payable for
services which have been made by BEACH BOULEVARD CHIROPRACTIC, LLC at the request of with the knowledge of
the undersigned and/or the make of the check, draft or money order.

Further more, the undersigned allows BEACH BOULEVARD CHIROPRACTIC, LLC or any of its agents to sign any paper
will be necessary to enhance, expedite, and/or allow payment to said provider. This may include, buy is not limited to,
affidavits of non-ownership of vehicles, insurance forms, other statements and appeals as necessary (i.e. reductions or
denied claims and/or procedures).

The undersigned by these presents does give and grand the said BEACH BOULEVARD CHIROPRACTIC, LLC as
attorney the full power and authority to do and perform all and every act whatsoever requisite and necessary to be done in
and about the premises as fully to all intents and purposes as the undersigned might or could do to personally present insofar
as the endorsing and cashing of said checks are concerned as well as any other document.

MEDICAL RELEASE

A photocopy of this document shall be sufficient to authorize any person having records of medical treatment, services, or
supplies pertaining to me release true copies of same to BEACH BOULEVEARD CHIROPRACTIC, LLC or any insurer
providing coverage to me in connection with the processing of any claim for benefits made by me or by assignees herein. A
photocopy of this document shall be binding as an original signature page.

The undersigned does hereby ratify and confirm any and all actions taken by the said attorney in accordance with this
special poser and which the said attorney shall do or cause to be done by virtue of these presents.

ASSIGNMENT OF BENEFITS

I,________ _______________________ hereby authorize _____________________________

(Name of Insured/Patient) (Name of Insurance Carrier)

to make medical benefits payments otherwise payable to me for services rendered by BEACH BOULEVARD
CHIROPRACTIC, LLC, but not exceed the charges of those services, payable to and mailed directly to:

BEACH BOULEVARD CHIROPRACTIC, LLC

11915 Beach Blvd Suite 105
Jacksonville, FL 32246

Furthermore, I hereby IRREVOCABLY ASSIGN to BEACH BOULEVARD CHIROPRACTIC, LLC, the rights and
benefits under any policy of insurance, indemnity agreement, or any collateral source as defined in Florida Statutes for any
service and or charges provided by BEACH BOULEVARD CHIROPRACTIC, LLC.

IN WITNESS WHEROF the undersigned have hereunto set their hands, this ______ day of_____________ 20___.

_____________________________________ ____________________________________
PATIENT'S SIGNATURE PATIENT'S NAME (PLEASE PRINT)
This 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 Health Insurance Portability & Accountability Act of 1996 (HIPPA) is a federal program
that requires that all medical records and other individually identifiable health information used or
disclosed by us in any for, whether electronically, on paper, or orally, are kept properly confidential.
This act gives you, the patient, significant new rights to understand and control how your health
information is used. HIPPA provides penalties for covered entities that misuse personal health
information.
As required by HIPPA, we have prepared this explanation of how we are required to maintain
the privacy of your health information and how we may use and disclose your health information.
We may use and disclose your medical records only for each of the following purposes:
treatments, payment, and health care operations.
Treatment means providing, coordinating, managing health care and related services by one or
more health care providers. An example of this would include a physical examination.
Payments refer to such activities as obtaining reimbursement for services, confirming coverage,
billing or collection activities and utilization review. An example would be sending a bill for
your visit to your insurance company for payments.
Health care operations include the business aspects of running our practice, such as conducting
quality assessment, improvement activities, auditing functions and case management analysis as
well as customer service. An example would be internal quality assessment review.

We may contact you to provide reminders along with test results, treatment and medication
information. This information may be left on your voice mail, answering machine an or sent to you via
fax, only with written consent.

You have the following rights with respect to your protected health information, which you can
exercise by presenting a written request to the privacy officer:
The right to request restrictions on certain uses and disclosures of protected health information,
including those related to disclosures to family members, other relatives, close personal friends
and any other person identified by you. This information may only discussed with your written
consent.
The right to inspect and copy your protected health information.
The right to amend your protected health information.
The right to receive an accounting of disclosures of protected health information.
The right to obtain and we have the obligation to provide to you paper copy of this notice from
us at the time of service.

11915 Beach Blvd Suite 105 Jacksonville, Fl 32246

Tel: (904) 683-0793 Fax: (904) 619-4740
www.BeachBlvdChiro.com