WORKERS COMPENSATION PATIENT QUESTIONNAIRE

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WORKERS’ COMPENSATION PATIENT QUESTIONNAIRE

Dear Patient/Injured Worker:

It is important in a workers’ compensation case to establish a

complete and accurate base of personal and historical information.

This information often becomes a critical part of the decision making

process in coming to final determinations or conclusions about your

case. Therefore, your help and cooperation in answering this

questionnaire as completely and accurately as possible is

necessary and appreciated. This is very important to the people

involved in handling your case and for you to receive appropriate and

fair compensation.

PLEASE, REVIEW AND COMPLETE THIS

PATIENT

QUESTIONNAIRE.

DOING

THIS,

WILL SIGNIFICANTLY REDUCE YOUR TIME

IN THE OFFICE. THE AMOUNT OF TIME,

WHICH HAS BEEN SCHEDULED FOR YOUR

APPOINTMENT,

DOES

TAKE

INTO

CONSIDERATION THAT THIS HAS BEEN

DONE. THANK YOU VERY MUCH!

PHYSICIAN USE ONLY:

Evaluation Date: _______________

Evaluation Began:

___________ A.M. P.M. _

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EMPLOYEE INFORMATION:

Name: ______________________________________ Birthday: _________ Sex  M  F

Address: ___________________________ City ______________________ State _______ Zip _______ Social Security #__________________ Home Ph: ________________ Work/Cell _________________ E-Mail _____________________ Height: _______ Weight: _______

__ Right Handed __ Left Handed __ Both

Employer Information: (Your Employer At The Time You Were Injured)

Name Of Business: _________________________________ Phone No.: (____) ___________________ Address: ____________________________________________________________________________

WORKERS' COMPENSATION INSURANCE CARRIER INFORMATION:

Name: ___________________________________________ Phone No.: (____) ___________________ Address: ____________________________________________________________________________ Claims Representative: _____________________________ Fax No.: (____) ______________________ Claim No.: __________________________________________________________________________

INFORMATION ABOUT YOUR WORK INJURY:

Date Of Injury: _____________ Time The Injury Occurred: __________ ____ A.M. ____ P.M. Date You Reported Your Injury To Your Employer/Supervisor: _________________________

Name Of Person You Reported Your Injury To: _____________________________________________ Where Did Your Injury Occur? (Address Or Description Of Location): __________________________ ____________________________________________________________________________________

ATTORNEY INFORMATION: ( ) Check If None

Name: ___________________________________________ Phone No.: (____) ___________________ Address: ____________________________________________________________________________

Our office offers appointment reminders via text messages OR E-Mail, which would you prefer? If you prefer text message, what is your cell provider (i.e. Verizon, Sprint)?

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JOB DESCRIPTION:

What Is Your Job Title? (AT THE TIME OF YOUR INJURY): ______________________________

When Did You Start Working For This Employer? ___________

How Many Hours Per Day Do You Normally Work? ___________ What Hours Do You Normally Work? ___________

How Many Days Per Week Do You Work? _________How Many Days In A Row? _________ How Long Is Your Lunch Break? ___________ How Long Are Your Rest Breaks? __________ How Many Rest Breaks Do You Get In A Normal Work Shift? ___________

What Percent Of Your Work Day Do You Work Indoors? ________% Outdoors? ________%

Check any that you perform throughout your day?

Leave blank if it doesn’t apply.

___ Sit ___ Squat ___ Reach ___ Keyboard ___ Finger ___ Walk ___ Climb ___ Crawl ___ Type ___ Grasp ___ Stand ___ Bend ___ Push ___ Mouse ___ Kneel ___ Twist ___ Pull ___ Write ___ Work Overhead

___ Flex/Twist/Side-Bend/Extend Your Neck

Please List Your Job Duties/Activities At Work: (WHEN YOU WERE INJURED)

A) _______________________________________________________________________________ B) _______________________________________________________________________________ C) _______________________________________________________________________________ D) _______________________________________________________________________________ E) _______________________________________________________________________________ F) _______________________________________________________________________________ G) _______________________________________________________________________________

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Are You Required To Lift At Work? ___ YES ___ NO If ‘YES’, Please Answer The Following:

Objects Lifted Weight In Pounds Times Per Day Distance Carried/Feet

1) ________________ ________________ ________________ ________________

2) ________________ ________________ ________________ ________________

3) ________________ ________________ ________________ ________________

4) ________________ ________________ ________________ ________________

5) ________________ ________________ ________________ ________________

What Is the Heaviest Weight That You Are Required To Lift At Work? __________ Pounds Do You Have To Bend Over Or Lean Forward While Lifting? ___ YES ___ NO

Are You Able To Lift The Same Amount Of Weight Now, As Before The Injury? ___ YES ___ NO If ‘NO’, Please Explain What You Could Lift Before And What You Can Lift Now: ____________ ____________________________________________________________________________________ ____________________________________________________________________________________ Does Your Job Require You To Reach Below, Above Or At Shoulder Level? ___ YES ___ NO If ‘YES’, Please Explain: ______________________________________________________________ ____________________________________________________________________________________ Are You Required To Move Your Feet In A Repetitive Movement/Activity? ___ YES ___ NO

If ‘YES’, Please Describe: ______________________________________________________________ ____________________________________________________________________________________ Are You Required To Use Your Hands For Fine Manipulation, Grasping, Pushing, Pulling, Torquing? ___ YES ___ NO If ‘YES’, Please Describe: ____________________________________________ ____________________________________________________________________________________ Are You Exposed To Dust, Gas, Fumes, Vapors, Noise, Or Extreme Temperatures Or Humidity?

___ YES ___ NO If ‘YES’, Please Explain: _____________________________________________ ____________________________________________________________________________________ Are You Required To Work At Heights Or Walk On Uneven Ground? ___ YES ___ NO If ‘YES’, Please Describe: ______________________________________________________________________ ____________________________________________________________________________________ Are You Required to Drive Vehicles Or Work Near Hazardous Equipment? ___ YES ___ NO

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If ‘YES’, Please Describe: ______________________________________________________________ Do You Have Any Special Seeing/Visual Or Hearing Requirements? ___ YES ___ NO If ‘YES’, Please Describe: ______________________________________________________________________ ____________________________________________________________________________________ Are You Able To Perform Your Normal Work Duties? ___ YES ___ NO If ‘NO’, Please Explain What Activities You Can’t Do, Or Have Difficulty Performing: _____________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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CURRENT SYMPTOMS:

Mark The Areas On Your Body Where You Are Having Symptoms From Your Work Injury(ies). Also, Review The Pain Scale On The Bottom Of This Page. The Doctor Will Be Asking You Questions. P = Pain N = Numbness/Tingling T = Tenderness B = Burning R = Radiating

PAIN SCALE

0-1 = Minimal = The pain is an annoyance but does not stop me from working.

2-3 = Slight = I can tolerate the pain but it causes some difficulty in doing my work. However, it does not stop me from working.

5 = Moderate = The pain causes a marked handicap in my ability to work, but I can continue.

7-8 = Moderate

To Severe

= The pain is approaching the worst I have ever experienced or could imagine. It causes a significant problem with working and most of the time I can't.

10 = Severe = The pain is the worst I have ever experienced or could imagine and causes me to stop all work and activity.

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Please list your current symptoms/complaints RESULTING FROM YOUR WORK INJURY: Complaint #1: _______________________________________________________________________ What Percentage Of The Time Do You Experience/Feel This Symptom? ________%

What Activities Make This Symptom Worse? ______________________________________________ ____________________________________________________________________________________ What Makes This Symptom Better? ______________________________________________________ ____________________________________________________________________________________ Can/Do You Have This Symptom Without Activity? _________________________________________ Pain Scale ________________ 0 - 10. The Doctor Will Discuss This With You.

Complaint #2: _______________________________________________________________________ What Percentage Of The Time Do You Experience/Feel This Symptom? ________%

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____________________________________________________________________________________ What Makes This Symptom Better? ______________________________________________________ ____________________________________________________________________________________ Can/Do You Have This Symptom Without Activity? _________________________________________ Pain Scale ________________ 0 - 10. The Doctor Will Discuss This With You.

Is There A Time Of Day That You Feel Worse? ___ YES ___ NO If ‘YES’, Please Explain:

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

In The Last Two Months Has Your Condition? ___ Stayed The Same ___ Improved ___ Worsened ___ Fluctuated But Overall Has Stayed About The Same If Your Condition Has Worsened, Please Explain: __________________________________________ ____________________________________________________________________________________ If Your Condition Continues To Improve, Please Explain: ___________________________________ ____________________________________________________________________________________ Do You Feel That Your Condition Will Improve With Time? ___ YES ___ NO Please Explain: ____________________________________________________________________________________ Before This Work Injury, How Would You Describe Your Health? ___ Excellent ___ Good ___ Fair Or ___ Poor If ‘Fair’ Or ‘Poor’, Please Explain: __________________________________________ ____________________________________________________________________________________

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HISTORY OF THE INJURY:

Please Describe How Your Work Injury Occurred: __________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Please List The Injured Body Parts, As A Result Of Your Work Injury:

____________________________________________________________________________________

How Did Your Symptoms Come On? ___ Suddenly ___ Gradually If ‘Gradually’, Over What Period of Time? ______________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

When Did Your Realize/Know That You Were Injured? Explain: _______________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

HISTORY OF TREATMENT:

When Did You First Seek Treatment For Your Injury? Date: __________________

Did Your Employer Send You For Treatment? ___ YES ___ NO

Did You Seek Treatment On Your Own? ___ YES ___ NO

‘INITIALLY’, Did You Go To A Hospital/Emergency Room? ___ YES ___ NO If ‘YES’,

Answer The Questions Below. If ‘NO’, Go To The Name Of Doctor/Facility #1 On This Page.

Name Of Hospital/ER? ____________________________________ City: _______________________ Were You Admitted To The Hospital? ___ YES ___ NO If ‘YES’, How Long? _________________

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Describe The Type Of Treatment &/Or Diagnostic Testing That Was Done: ______________________ ____________________________________________________________________________________ What Did The Hospital Doctor(s) Say Was Wrong With You? _________________________________ ____________________________________________________________________________________ Were You Told That You Would Need More Treatment? ___YES ___ NO If ‘YES’, Explain: ____________________________________________________________________________________ Did The Doctor(s) Restrict Or Modify Your Work Activities? ___ YES ___ NO If ‘YES’, How? ____________________________________________________________________________________

Please list ALL Doctors You Have Seen Regarding Your Work Injury. Please List Them In Chronological Order/The Order You Saw Them In:

Name Of Doctor/Facility #1: _______________________ City/Location: ________________________ Type Of Doctor (degree or specialty): ___________________________________________________________ Describe Treatment And/Or Tests: _______________________________________________________ ____________________________________________________________________________________ What Did This Doctor Say Was Wrong With You? __________________________________________ ____________________________________________________________________________________ Date When Treatment Started: ________________ Date When Treatment Stopped: ________________ How Many Treatments/Visits Were There? ______ How Long Were The Treatments? ______________ What Was The Result/Outcome Of The Treatment? __________________________________________ ____________________________________________________________________________________ Still Treating With This Doctor? ___ YES ___ NO If ‘YES’, How Often? _____________________ Did This Doctor Take You Off Work? ___ YES ___ NO If ‘YES’, Give Dates: _________________ Did This Doctor Restrict Or Modify Your Work Activities? ___ YES ___ NO If ‘YES’, How? ____________________________________________________________________________________ Did This Doctor Say You Would Need More Treatment? ___ YES ___ NO If ‘YES’, Explain: ____________________________________________________________________________________ Did This Doctor Refer You Anywhere Else? ___ YES ___ NO If ‘YES’, Where And Why?

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Name Of Doctor/Facility #2: _______________________ City/Location: ________________________ Type Of Doctor (degree or specialty): ___________________________________________________________ Describe Treatment And/Or Tests: _______________________________________________________ ____________________________________________________________________________________ What Did This Doctor Say Was Wrong With You? __________________________________________ ____________________________________________________________________________________ Date When Treatment Started: ________________ Date When Treatment Stopped: ________________ How Many Treatments/Visits Were There? ______ How Long Were The Treatments? ______________ What Was The Result/Outcome Of The Treatment? __________________________________________ ____________________________________________________________________________________ Still Treating With This Doctor? ___ YES ___ NO If ‘YES’, How Often? _____________________ Did This Doctor Take You Off Work? ___ YES ___ NO If ‘YES’, Give Dates: _________________ Did This Doctor Restrict Or Modify Your Work Activities? ___ YES ___ NO If ‘YES’, How? ____________________________________________________________________________________ Did This Doctor Say You Would Need More Treatment? ___ YES ___ NO If ‘YES’, Explain: ____________________________________________________________________________________ Did This Doctor Refer You Anywhere Else? ___ YES ___ NO If ‘YES’, Where And Why?

____________________________________________________________________________________ Name Of Doctor/Facility #3: _______________________ City/Location: ________________________ Type Of Doctor (degree or specialty): ___________________________________________________________ Describe Treatment And/Or Tests: _______________________________________________________ ____________________________________________________________________________________ What Did This Doctor Say Was Wrong With You? __________________________________________ ____________________________________________________________________________________ Date When Treatment Started: ________________ Date When Treatment Stopped: ________________ How Many Treatments/Visits Were There? ______ How Long Were The Treatments? ______________ What Was The Result/Outcome Of The Treatment? __________________________________________ ____________________________________________________________________________________ Still Treating With This Doctor? ___ YES ___ NO If ‘YES’, How Often? _____________________ Did This Doctor Take You Off Work? ___ YES ___ NO If ‘YES’, Give Dates: _________________

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Did This Doctor Restrict Or Modify Your Work Activities? ___ YES ___ NO If ‘YES’, How? ____________________________________________________________________________________ Did This Doctor Say You Would Need More Treatment? ___ YES ___ NO If ‘YES’, Explain: ____________________________________________________________________________________ Did This Doctor Refer You Anywhere Else? ___ YES ___ NO If ‘YES’, Where And Why?

____________________________________________________________________________________

If you saw any additional physicians please list them on the back and answer the same questions as previous physicians.

Were Any Other Tests, Examinations, Treatments, or Therapy Done That Were Not Described Above? ___ YES ___ NO If ‘YES’, Please Describe What Was Done And What The Result Was: (use the back of this page if necessary): ________________________________________________________

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Do You Treat Yourself? ___ YES ___ NO If ‘YES’, Please Explain How: _____________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Are You Currently Taking Medication To Relieve The Effects Of This Injury? ___ YES ___ NO If ‘YES’, Please Describe What You Take, (Prescription or Non-Prescription), How Much It Helps, How Often You Take It, Etc.: ___________________________________________________________ ____________________________________________________________________________________ Are You Currently Using A Brace, Support, Cane, Crutch(es), Wheelchair, TENS Unit, Or Other

Aid Because Of The Effects Of This Injury? ___ YES ___ NO If ‘YES’, Please Describe Type And How Often It Is Used: _____________________________________________________________ ____________________________________________________________________________________ What Treatment(s) Offer You The Most Relief, And How Long Do The Benefits Last?

____________________________________________________________________________________ ____________________________________________________________________________________

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Have There Been Any Recommendations For Diagnostic Testing Or Treatment That You Have Not Received? If ‘YES’, What Was Recommended, And Who Recommended It?

____________________________________________________________________________________ ____________________________________________________________________________________ HISTORY OF OTHER INJURIES:

Have You Ever Experienced The Same Or Similar Symptoms/Problems BEFORE This Work Injury? ___ YES ___ NO If ‘YES’, Please Explain In Detail:

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Have You Ever Had A PRIOR, Work Injury(ies)? ___ YES ___ NO If ‘YES’, Please Explain: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Have You Ever Received a PRIOR, Workers’ Compensation Disability Award? ___ YES ___ NO If ‘YES’, Please Explain: _______________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Have You Ever Served In The Military? ___ YES ___ NO If ‘YES’, Did You Receive A Medical Discharge? ___ YES ___ NO If ‘YES’, Please Explain Why: _______________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Have You Ever Had Any PRIOR, NON-WORK RELATED INJURIES? (e.g. Sprains/Strains,

Slips/Falls, Motor Vehicle Accidents, Cumulative Or Repetitive Traumas, etc.) ___ YES ___ NO If ‘YES’, Please Explain: _______________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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Have You Had Any NEW INJURIES Involving Body Parts Which Are A Part Of Your Current

Work Injury? ___ YES ___ NO If ‘YES’, Please Explain: __________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ WORK HISTORY:

Did You Have More Than One Employer When You Were Injured? ___ YES ___ NO If ‘YES’, Please List The Employer(s), And The Activities Required At That Employment?

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ If ‘YES’, Did The Other Employment/Activities Listed Above Contribute To, Or Further Worsen Your Condition? ___ YES ___ NO If ‘YES’, Please Explain How? _________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Please List Your Employers, Where Your Current Injury Occurred:

Employer Dates Of Employment Job Title/Duties

A) _________________________ _________________________ _________________________ B) _________________________ _________________________ _________________________ C) _________________________ _________________________ _________________________ D) _________________________ _________________________ _________________________ E) _________________________ _________________________ _________________________ F) _________________________ _________________________ _________________________

Are You Still Working For The Same Employer Where Your Work Injury Occurred? ___ YES ___ NO If ‘NO’, Answer The Questions Below. If ‘YES’, Skip The Following Questions And Go To The Next Section Entitled ‘PAST MEDICAL HISTORY.’

Why Aren't You Working For The Same Employer Now? _____________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ When Did You Stop Working For The Same Employer? ______________________________________

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If You Are Not Working For The Same Employer As When You Were Injured, Please List Your Employment Since Leaving: ___ I Have Not Worked Since Leaving That Employment

Employer Dates Of Employment Job Title/Duties

A) _________________________ _________________________ _________________________ B) _________________________ _________________________ _________________________ C) _________________________ _________________________ _________________________ D) _________________________ _________________________ _________________________ E) _________________________ _________________________ _________________________ F) _________________________ _________________________ _________________________

Who Is Your Current Employer(s)? _____________________________________________________ Are You Doing The Same Type Of Work? ___ YES ___ NO

If ‘NO’, Describe The Type Of Work You Are Doing Now, Including Details On Physical Activity: ____________________________________________________________________________________ ____________________________________________________________________________________ Has Any NEW Job Or Employment Contributed To, Or Further Worsened Your Condition?

___ YES ___ NO If ‘YES’, Please Name The Employer(s) And Explain How?

____________________________________________________________________________________ ____________________________________________________________________________________ Are You Going To Be Retrained For Another Job/Occupation As A Result Of This Work Injury? ___ YES ___ NO ___ I DO NOT KNOW ___ RECOMMENDED Please Describe:

____________________________________________________________________________________ ____________________________________________________________________________________ PAST MEDICAL HISTORY:

Please List The Information About Your Medical History In The Sections Below, With The Approximate Dates. If A Section Does Not Apply To You, Simply Mark An (X) In The ‘Denied’ Box: Childhood Illnesses: ( ) Denied _________________________________________________________ Childhood Injuries: ( ) Denied __________________________________________________________ Allergies: ( ) Denied __________________________________________________________________

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Present Medications Taken (Prescription & Over-The-Counter): ( ) Denied ______________________ ____________________________________________________________________________________ Surgeries: ( ) Denied _________________________________________________________________ Hospitalizations: ( ) Denied ____________________________________________________________ Adult Illnesses: ( ) Denied _____________________________________________________________ Doctor(s) Seen Previous To Your Current Work Injury: Name & Location/City: ( ) Denied _________ ____________________________________________________________________________________ FAMILY HISTORY:

List Any Health Problems In Your Immediate Family: (Mother, Father, Brother, Sister) ( ) Denied ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ REVIEW OF SYSTEMS:

Please List Any Problems That You Now Have With The Following Body Systems:

Ears/Nose/Throat: ( ) Denied ___________________________________________________________ Eyes: ( ) Denied _____________________________________________________________________ Lungs: ( ) Denied ____________________________________________________________________ Liver: ( ) Denied _____________________________________________________________________ G-I Tract (Stomach, Intestines, Bowels, Etc.): ( ) Denied _____________________________________ Kidney/Bladder: ( ) Denied _____________________________________________________________ [Women] Reproductive System: ( ) Denied ________________________________________________ Skin: ( ) Denied ______________________________________________________________________ Neurological: ( ) Denied _______________________________________________________________ Heart/Circulation: ( ) Denied ___________________________________________________________ Psychological: ( ) Denied ______________________________________________________________ OFF WORK ACTIVITIES:

Do You Exercise? ___ YES ___ NO If ‘YES’, Please Describe Type & Frequency. If ‘NO’, Please Explain Why You Don’t: _______________________________________________________________ ____________________________________________________________________________________ Do You Participate In Any Sports Activities? ___ YES ___ NO If ‘YES’, Please Describe Type & Frequency: __________________________________________________________________________

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Do You Have Any Hobbies? ___ YES ___ NO If ‘YES’, Please Describe Type & Frequency:

____________________________________________________________________________________ ____________________________________________________________________________________ Are You Able To Perform Your Normal/Regular Household Chores/Activities? ___ YES ___ NO If ‘NO’, Please Explain What You Cannot Do & Why: _______________________________________ ____________________________________________________________________________________ SOCIAL HISTORY:

Are You? ( ) Married ( ) Single ( ) Separated ( ) Divorced ( ) Widowed

How Many Years Of Schooling Have You Had? ____________________________________________ List Degrees, Diplomas, Licenses, Certifications You Hold: ___________________________________ Do You Use Alcohol? ___ YES ___ NO If ‘YES’, How Many Drinks Per Week? _______________ Do You Use Tobacco? ___ YES ___ NO If ‘YES’, What Kind & Times Per Day Or Week?

____________________________________________________________________________________ Do You Use Drugs? ___ YES ___ NO If ‘YES’, What Kind & How Many Times Per Day Or Week? ____________________________________________________________________________________ Do You Drink Coffee? ___YES ___NO If “YES”, How Many Cups Per Week? ___________________ List Any Other Habits, Describing Their Type & Frequency: __________________________________ ____________________________________________________________________________________

THANK YOU FOR YOUR TIME IN COMPLETING THIS QUESTIONNAIRE!

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17 Patient Name ___________________________________________

ARBITRATION AGREEMENT

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, including whether any medical services

rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Further, the parties will not have the right to participate as a member of any class of claimants, and there shall be authority for any dispute to be decided on a class action basis. Anrbitration can only decide a dispute between the parties and may not consolidate or join the claims of other persons who have similar claims.

Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including

disputes as to whether or not a dispute is subject to arbitration, as to whether this agreement is unconscionable, and any procedural disputes, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the health care provider including any heirs or past present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers, preceptors, or interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the health care provider. Including those working at the health care provider's clinic or office or any other clinic or office whether signatores to this form or not.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider's associates, association, corporation. partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages. This agreement is intended to create an open book account unless and until revoked.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall

select an arbitrator (party arbitrator) within thirty days, and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party's own benefit. Either party shall have the absolute right to bifurite the issues of liability and damage upon written request to the neutral arbitrator.

The parties cosent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of the California Medical Injury Compensation Reform Act shall apply to disputes within this arbitration agreement, including, but not limited to, sections establishing the right to introduce evidence of any amount payable as a benefit to the patient as allowed by law (Civil Code 3333.1), the limitation on recovery for non-economic losses (Civil Code 3333.2), and the right to have a judgment for future damages conformed to periodic payments (CCP 667.7). The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement.

Article 4: General Provision: All claims based upon the same incident, transaction, or related circumstances shall he arbitrated in one

proceeding. A claim shall be waived end forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature

and, if not revoked, will govern all professional services received by the patient and all other disputes between the parties.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example,

emergency treatment), patient should initial here.______. Effective as of the date of first professional services.

If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

________________________________________ _________________ ___________________________________ Patient Signature (Or patient representative) Date (Indicate relationship if signing for patient)

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Informed Consent for Examination and Treatment

I (we) hereby consent to the performance of examination and treatment on me or on

_____________________________________, by the licensed doctors of chiropractic, medical doctors, and/or licensed physical therapists who may be employed by or engaged in practice in this clinic.

I have had an opportunity to discuss with the doctor(s) or other clinic personnel the nature and purpose of the different physical therapy procedures and chiropractic treatment (manipulation/adjustment). I understand that neither chiropractic nor medical treatment is an exact science and that my care may involve judgments based upon facts and information known to the doctor. The doctor uses this

judgment to attempt to anticipate or explain risks and complications and an undesirable result does not necessarily indicate an error in judgment. No guarantee for results can be made or expected but rather I wish to rely on the doctor to choose and recommend a best course of treatment based upon facts known that is in my best interests.

I further understand that there are certain degrees of risk associated with chiropractic health care and physical therapy, which includes rarely, but not limited to fractures, disc injuries, strokes, and

strain/sprains and am therefore willing to accept and consent to the risk associated with the care that I am about to receive.

I have read, or the above information has been explained regarding consent. I have had an opportunity to ask questions about my examination and treatment. By signing below, I agree and intend this

consent form to cover the procedures prescribed for my condition and for any future conditions for which I seek treatment.

Female Patients: By my signature on this form I do hereby state that to the best of my knowledge, I am not pregnant, nor is pregnancy suspected or confirmed at this particular time. Date of last menstrual period _____________.

_____________________________ _____________________________

Patient’s Name (Print) Patient’s Signature

___________ _____________________________

Date Relationship or authority if not

signed By patient

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OFFICE FINANCIAL POLICY

Our policy is to extend to you the courtesy of allowing you to assign your insurance benefits directly to us. The policy reduces your out-of-pocket expense and allows you to place your family under care.

1. If You Do Not Have Insurance: All payments are expected at the time of service or by an authorized payment plan. Your

personal balance may not exceed $100 at any time or care may be terminated. Our payment plans make care an affordable part of your family budget.

2. If You Have Insurance: I acknowledge that I am legally responsible for all charges in connection with the medical care

and treatment provided by representatives of Unruh Chiropractic, Inc. or Thrive Medical, Inc. I assign and authorize payments to Unruh Chiropractic, Inc. or Thrive Medical, Inc. I understand my insurance carrier may not approve or reimburse my medical services in full due to usual and customary rates, benefit exclusions, coverage limits, lack of authorization, or medical necessity. I understand I am responsible for fees not paid in full, co-payments, and policy deductibles and co-insurance except where my liability is limited by contract or State or Federal law.

All deductibles and co-payments are expected at the time of service or by an authorized payment plan. Your co-insurance balance may not exceed $100 or care may be terminated. Our payment plans make care an affordable part of your family budget.

Insurance figures are ESTIMATES ONLY! It is not easy for an office to become familiar with the exact details of every Insurance Plan it encounters. It is the responsibility of the patient, NOT the doctors’ office to know what is covered and

what is excluded from their particular Insurance Plan.

You are considered a cash patient until you bring in your completed insurance forms, and we qualify and accept your

insurance coverage. We DO NOT accept assignment for secondary insurance carriers, but will be happy to provide you

with a claim form for your secondary carrier.

Our fees are considered usual, customary and reasonable by most companies, and therefore are covered up to the maximum allowance determined by each carrier. This statement does not apply to companies who reimburse based on arbitrary schedule of fees bearing no relationship to the current standard of care in this area. If your carrier has not paid a claim

within sixty (60) days of submission, you agree to take an active part in the recovery of your claim.

If your insurance carrier has not paid within ninety (90) days of submission, you accept responsibility for payment in full of any outstanding balance.

As the patient you agree that you are seeking care under your accord if your insurance denies your care for any reason, including but not limited to medical necessity, timely filing, etc.

Cancellation Fee: We do not over-book our physician’s schedules. We want every patient to be able to receive the care that

they need. Therefore, when you cancel or do not show up to your appointment you are preventing someone else from getting the care they need.

If you do not cancel your appointment within 4 hours of your scheduled time or if you do not show up to your appointment you will be charge a $25 cancellation fee due on your next date of service.

_______________________________________ ______________

Signature of Patient or Guardian Date

_______________________________________ _________________________

WORKERS COMPENSATION PATIENT QUESTIONNAIRE