Davis Integrated Medicine 973-783-3606 316 Orange Road .

Davis Integrated Medicine 973-783-3606 316 Orange Road, Montclair NJ www.davisintegratedmedicine.comPatient InformationDate:Name:LastFirstMIEmail address:Mailing Address:City: State: Zip:Phone #(H)(Cell)Can we call you at work? Yes NoSex: Male FemaleDate of Birth:Marital Status: Single Married Divorced WidowedSS#: Separated MinorOccupation:How did you hear about our practice?Emergency contact: Name:Relation:Phone #:(W)(H)Phone #:Accident InformationIs this visit due to an accident? YesHas it been reported? Yes No If yes, what type? Auto Work Other NoIf yes, to whom?Do you have health insurance? Yes NoName of Carrier:Do you have secondary insurance? Yes NoName of Carrier:Financial Office Policies1. All Auto Immune patients are on a cash basis.2. Any and all services, supplements and in office testing will be the patient’s responsibility.3. If your account should go to collections for any reason, it will be the patient’s responsibility for any court costs,attorney’s fees, and or collection costs incurred in collecting the account balance.4. If this office gives you any professional or accounting discount for treatment and you decide to drop out of carethen our standard fees will apply.5. This office accepts MasterCard, Visa, Discover Card, personal checks and cash.6. If you have any questions concerning this or any other matter, please speak with the receptionist prior to seeingthe doctor.7. If you stop care and have a financial agreement signed with our office, you will beresponsible for any/all charges that you have incurred at our office.Thank you for your cooperation in this matter.I have read and fully understand the financial office policy and agree to abide by these terms.Patient Signature or Responsible Party/ /Date

Davis Integrated Medicine 973-783-3606 316 Orange Road, Montclair NJ www.davisintegratedmedicine.comPrimary Health ConcernsWho is your primary care physician? (Doctor and/or practice)PLEASE ADDRESS WHAT BRINGS YOU TO OUR OFFICE:Health concerns listAccording to severity1.2.3.4.Rate of Severity1 Mild10 SevereWhen did thisepisode start?If you had thecondition before,when?Did the problem Are symptomsbegin withconstant oran injury?intermittent?Please check to indicate if you are currently or have ever experiencing any of the following conditions: Alcoholism Fatigue Pins/Needles in Legs Allergies Fractures Pneumonia Allergy Shots Glaucoma Polio Anemia Goiter Prostate Problems Ankle Swelling Gout Prosthesis Anorexia Hair Loss Psychiatric Care Appendicitis Headaches Rheumatic Fever Arm/Hand Pain Heart Disease Rheumatoid Arthritis Arthritis Hepatitis Scarlet Fever Asthma Herniated Disc Shortness of Breath Asthma High Blood Pressure Sinus Back Pain/Stiffness High Cholesterol Skin Rashes Bleeding Disorders Jaw Problems Sleeping Difficulties Blurred Vision Kidney Disease Stomach Problems Bowel/Bladder Changes Leg/Knee Pain Strep Throat Breast Lump Light Bothers Eyes Stroke Bronchitis Liver Disease Sudden Weight Loss Bulimia Loss of Memory Suicide Attempt Cancer Loss of Smell Tension Cataracts Loss of Taste Thyroid Problems Chemical Dependency Low Body Temp Tonsillitis Chest Pain Measles Tuberculosis Chicken Pox Migraines Tubes in Ears Cold Feet/Hands Miscarriage Tumors/Growths Cold Sores Mononucleosis Typhoid Fever Cold Sweats Mumps Ulcers Constipation Nausea Vaginal Infections Depression Neck Pain/Stiffness Varicose Veins Diabetes Nervousness Venereal Disease Dizziness Osteoporosis Whooping Cough Emphysema Pacemaker Other Epilepsy Pinched Nerve Fainting Pins/Needles in ArmsIs there a family history of any of the following conditions? (indicate family member including parents, grandparents &siblings) Arthritis Autoimmune Cancer Diabetes Heart Disease Neurological Diseases Other

Davis Integrated Medicine 973-783-3606 316 Orange Road, Montclair NJ www.davisintegratedmedicine.comPrimary Health Concerns continued Received A Diagnosis For ANY Condition By Another Health Care Provider? Y NIf Yes, What Was The Diagnosis?Who Provided the Diagnosis?Medication NameDosageReasonSupplement Name/BrandDosageReasonPlease list any allergies:Do you exercise: Frequently ModeratelyDoes your work activity mostly involve? Sitting Standing Occasionally Light LaborWhat is your daily/weekly intake of the following:Caffeinecups/day Alcoholdrinks/week None Heavy LaborCigarettespacks/dayHave you ever been exposed to mold? Yes NoHave you ever been exposed to chemicals (work, pesticides, etc.)? Yes NoSleep/Rest:Average number of hours you sleep: more than 10Do you have trouble sleeping? Yes NoDo you have problems falling asleep? Yes NoDo you have problems staying asleep Yes NoDo you feel rested upon awakening? Yes NoDo you have problems with insomnia? Yes NoDo you snore? Yes NoDo you use sleeping aids? Yes No8 to 10 6 to 8 less than 6

Davis Integrated Medicine 973-783-3606 316 Orange Road, Montclair NJwww.davisintegratedmedicine.comIs there anything else you would like Dr. Davis to know?I certify that the above questions were answered accurately. I understand that providing incorrectinformation can be dangerous to my health.SIGNATURE (X)DATECONSENT TO CAREA patient coming to the doctor gives him/ her permission and authority to care for them inaccordance with appropriate test, diagnosis, and analysis. The clinical procedures performed areusually beneficial and seldom cause any problem. In rare cases underlying physical defects,deformities or pathologies, may render the patient susceptible for injury. The doctor, of course, will notprovide specific healthcare, if he/ she is aware that such care may be contraindicated. It is theresponsibility of the patient to make it known or to learn through health care procedures from whateverhe/ she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwisenot come to the attention of the physician.I agree to settle any claim or dispute I may have against or with any of these persons or entities,whether related to the prescribed care or otherwise, will be resolved by binding arbitration under thecurrent malpractice terms which can be obtained by written request.I have read and understand the foregoing.Patient’s SignatureDate

Davis Integrated Medicine 973-783-3606 316 Orange Road, Montclair NJwww.davisintegratedmedicine.com

Davis Integrated Medicine 973-783-3606 316 Orange Road, Montclair NJwww.davisintegratedmedicine.comHow does this condition affect your daily activities?ACTIVITIES OF DAILY LIVINGBendingCarrying groceriesChanging postitions(Sit to stand)Climbing stairsDrivingExtended Computer UseHousehold choresKneelingLifting (over 10 lbs)Hobbies or SportsReading (concentration)BathingGetting DressedSexual activitiesSleepingSittingStandingWalkingYard WorkNoMildly painfulModeratelySeverely Painfuleffect(Can do)Painful(Unable to(Limited)perform)

Davis Integrated Medicine 973-783-3606 316 Orange Road, Montclair NJwww.davisintegratedmedicine.comOffice HoursMonday-Wednesday: 8am-12pm & 2pm6pmThursday 2pm-6pmFriday 8am-12pmHablamos EspanolMost insuranceacceptedPayment plansavailableSome of the Conditions We SpecializeIn Treating: Back PainNeck PainHeadaches/MigrainesFibromyalgiaKnee and Foot PainCarpal TunnelHigh Blood PressureDisc ProblemsArthritisDiabetesSciaticaThyroid IssuesAuto Immune DiseasesJoint Pain, Hip and TMJ PainDIRECTIONS COMMON DIRECTIONS: From BloomfieldAve. (West heading into Montclair) Make aleft turn on Elm Street. Landmarks include:Lackawanna Plaza Pathmark Supermarket, Firestone Tire and Exxon gas station.Travel approximately 1 mile, Elm Street will turn into Orange Road (bear to the left). The roadway will fork,take it (to the right, you have no choice). Travel through the traffic light, continue one block, stay in the leftlane and make a left-handed jug handle turn. Look for 316 Orange Road, on your LEFT hand side (CORNEROF ORANGE ROAD AND WASHINGTON AVE). There is parking in the Municipal Lot behind our office ormetered on the street. FROM POINTS SOUTH: Take the Garden State Parkway North, get off atexit 148 (Bloomfield Avenue)Travel through the first traffic light and in the left lane, make a left jughandle. Make a right at the next traffic light (Bloomfield Ave.) FROM POINTS NORTH: Take the Garden State Parkway South, get offat exit 148(Bloomfield Ave.) Make a right turn at the traffic light; it is quick(Montgomery St.)Make another right turn at the second traffic light (Bloomfield Ave.) 973-783-3606316 Orange RoadMontclair, NJwww.davisintegratedmedicine.comBY BUS: Take the #34 Montclair Bus (Montclair Center Bus) to the intersection of Orange Road &Washington Street: IT drops you off at a gazebo. Cross the street and Look for 316 Orange Road onthe left.

BY BUS: Take the #34 Montclair Bus (Montclair Center Bus) to the intersection of Orange Road & Washington Street: IT drops you off at a gazebo. Cross the street and Look for 316 Orange Road on the left. 973-