page 1 of 8© Dr. Lauren Nappen | Original Medicine, 2015 [personalhistory _2017] • www.drlaurennappen.com • 215-794-0606

The following pages offer me a glimpse into your life story. The same places, faces and

events that have fashioned and molded your life, have also created the circumstances

that have led you to this time of concern. In understanding your biography, your biol-

ogy comes into greater focus highlighting those ways of being that no longer serve

your best and highest good, while simultaneously igniting the passion and purpose

for your life that is your birthright.

Please take your time in filling this out. It is important, as are you.

In Peace,

page 2 of 8© Dr. Lauren Nappen | Original Medicine, 2015 [personalhistory _2017] • www.drlaurennappen.com • 215-794-0606

Terms of AcceptanceFor Children and Adults

These are the terms under which all practice members are accepted for care in this office.

The human body is designed to express health and function normally. However, events may occur that caninterfere with this natural ability. The approach of Original Medicine (inclusive only of the tools used in thisoffice,) is distinctly different and is not a replacement for medical treatment. While we could limit our focusto a symptom, restoring communication within you allows the greatest opportunities for growth and there-fore healing. It is under these parameters that you consent to receive care in this practice. The care offeredin this office is designed to empower how you move and live in this life.

It is clearly understood that there is no promise or offer of any kind, on the part of the doctor or this officeto treat any symptom, condition or disease. Although I may have brought myself or my child to this officewith the initial expectation of relief of a particular symptom or condition, it has been clearly explained tome that the main purpose of the care offered here is holistic in nature and not a replacement for appropri-ate medical care.

Should I feel that a different approach is needed for myself or my child it is my right and responsibility tofollow that inner guidance.

It is under these parameters that I consent to have my child receive care at this office:

It is under these parameters that I consent to receive care at this office:

Client Name: Date:

Client Signature: Date:

Child’s Name:

Parent Signature: Date:

Witness: Date:

page 3 of 8© Dr. Lauren Nappen | Original Medicine, 2015 [personalhistory _2017] • www.drlaurennappen.com • 215-794-0606

Personal History and Health Status Questionnaire

Name Date

Address

City State Zip

Telephone (HOMe) (CeLL)

(WOrk) (eMAIL)

Date of Birth:

referred By:

Have you ever been under chiropractic care? Yes No

Did it meet your objectives? Yes No

Occupation:

Questions for your Consideration

Please answer to the best of your ability

1. What do you feel is missing in your life?

2. How do you want to know yourself better?

3. What truth have you denied that you would like to explore?

4. What do you miss about yourself?

5. How do you want to participate in your life as you walk towards your destiny?

page 4 of 8© Dr. Lauren Nappen | Original Medicine, 2015 [personalhistory _2017] • www.drlaurennappen.com • 215-794-0606

Please check any or all that apply.

How do you hope to benefit from care in this office?

Improvement of my physical symptoms

Improvement of my mental/emotional symptoms

Improvement of my ability to react or respond to stress

Improvement in enjoyment of life and the ability to make constructive choices

Overall improved quality of life

Your Current Concerns

1. What are your current health and life concerns:

2. When did this situation or concern begin?

3. Have you consulted anyone else concerning this matter?

4. Was anything done and did it seem to work?

5. What was different about you after the treatment?

6. What was different about your condition after the treatment?

7. How aware of this are you during the day? 0 1 2 3 at night? 0 1 2 3

8. Is there any time or activity you can be involved with when you totally or almost

totally forget about this situation or concern?

9. Is there any time of day or activity which makes you more aware of it?

10. Why do you think this has happened or continues to happen to you?

11. Do you think this is the sole cause? Yes No

12. If no, what else is involved?

emotional Areas:

Mental/Stress Areas:

Spiritual Concerns:

13. If this condition or symptom were to go away tomorrow, what would be different

about your life?

page 5 of 8© Dr. Lauren Nappen | Original Medicine, 2015 [personalhistory _2017] • www.drlaurennappen.com • 215-794-0606

Current Life Stressors

Please grade the following stresses in order of increasing intensity with,

0 : no awareness of any stress 1 : slightly stressful 2 : moderately stressful 3 : extremely stressful

1. Overall Physical Stress, Trauma 0 1 2 3

Includes falls accidents, injuries, repeated postural stress, impacts, difficult birth, traction,

physical abuse

2. Overall Emotional/Mental Stress 0 1 2 3

Includes loss of loved ones, rapid change in life situation, mental, emotional, or sexual

abuse, legal concerns, financial concerns, move of home/school, separation/divorce, stress

of being ill

3. Overall Chemical Stress 0 1 2 3

Includes drugs, medications, smoke, fumes, additives, work environment

Past Life StressorsPlease tell us about any stresses related to your birth.

1. Drugs/medicine/tobacco/alcohol in pregnancy:

2. Labor chemically induced?

3. Forceps/vacuum extraction/C-section:

4. Premature delivery?

5. Vaccination?

6. Falls in first year of life?

7. Any health related problems?

Please tell us about any stresses associated with childhood.

1. Any falls or injuries?

2. Allergies/Asthma/respiratory Problems

3. ear Infections

4. Digestive Problems

5. Hyperactivity

6. Any other health related problems

Is there some aspect of your life that very much pleases you, brings you joy, or helps you to

feel better about yourself?

What factors in your current lifestyle/health-style add to your health and what factors do

you think detract from it?

page 6 of 8© Dr. Lauren Nappen | Original Medicine, 2015 [personalhistory _2017] • www.drlaurennappen.com • 215-794-0606

Physical State

rate the following questions on a frequency scale of 1 to 5 with,1: never 2: rarely 3: occasional 4: regularly 5: constantly

1. Presence of physical pain (neck/back ache, sore arms/legs…) 1 2 3 4 5

2. Feeling of tension, stiffness, or lack of flexibility in your spine. 1 2 3 4 5

3. Incidence of fatigue or low energy. 1 2 3 4 5

4. Incidence of colds or flu. 1 2 3 4 5

5. Incidence of headaches (any kind). 1 2 3 4 5

6. Incidence of nausea or constipation. 1 2 3 4 5

7. Incidence of menstrual discomfort. 1 2 3 4 5

8. Incidence of allergies or eczema or skin rash. 1 2 3 4 5

9. Incidence of dizziness or lightheadedness. 1 2 3 4 5

10. Incidence of accidents or near accidents, falling or tripping. 1 2 3 4 5

Mental/Emotional State

rate the following questions on a frequency scale of 1 to 5 with,1: never 2: rarely 3: occasional 4: regularly 5: constantly

1. If pain is present, how stressed are you about it? 1 2 3 4 5

2. Presence of negative or critical feelings about yourself. 1 2 3 4 5

3. experience of moodiness or temper or angry outbursts. 1 2 3 4 5

4. experience of depression or lack of interest. 1 2 3 4 5

5. Being overly worried about small things. 1 2 3 4 5

6. Difficulty thinking or concentrating or indecisiveness. 1 2 3 4 5

7. experience of vague fears or anxiety. 1 2 3 4 5

8. Fidgety or restless; difficulty sitting still. 1 2 3 4 5

9. Difficulty falling asleep or staying asleep. 1 2 3 4 5

10. experience of recurring thoughts or dreams. 1 2 3 4 5

Stress Evaluation

evaluate your stress relative to the following with,1: none 2: slight 3: moderate 4: pronounced 5: extensive

1. Family 1 2 3 4 5

2. Significant relationship 1 2 3 4 5

3. Health 1 2 3 4 5

4. Finances 1 2 3 4 5

5. Sex Life 1 2 3 4 5

6. Work 1 2 3 4 5

7. School 1 2 3 4 5

8. General Well Being 1 2 3 4 5

9. emotional Well Being 1 2 3 4 5

10. Coping with Daily Problems 1 2 3 4 5

page 7 of 8© Dr. Lauren Nappen | Original Medicine, 2015 [personalhistory _2017] • www.drlaurennappen.com • 215-794-0606

Life Enjoyment

rate the following on a scale of 1-5 with,1: not at all 2: slight 3: moderate 4: considerate 5: extensive

1. Openness to guidance by your "inner voice/feelings." 1 2 3 4 5

2. experience of relaxation or ease or well being. 1 2 3 4 5

3. Presence of positive feelings about yourself. 1 2 3 4 5

4. Interest in maintaining a healthy lifestyle. (i.e. diet, fitness.) 1 2 3 4 5

5. Feeling of being open & aware/connected when relating to others. 1 2 3 4 5

6. Level of confidence in your ability to deal with adversity. 1 2 3 4 5

7. Level of compassion and acceptance of others. 1 2 3 4 5

8. Satisfaction with the level of recreation in your life. 1 2 3 4 5

9. Incidence of feelings of joy and or happiness. 1 2 3 4 5

10. Level of satisfaction with your sex life. 1 2 3 4 5

Overall Quality of Life

evaluate your feelings relative to the quality of your life with,1: terrible 2: unhappy 3: mostly dissatisfied 4: mixed 5: mostly satisfied

6: pleased 7: delighted

1. Your personal life. 1 2 3 4 5 6 7

2. Your partner/significant other. 1 2 3 4 5 6 7

3. Your romantic life. 1 2 3 4 5 6 7

4. Your job. 1 2 3 4 5 6 7

5. Your co-workers. 1 2 3 4 5 6 7

6. The actual work you do. 1 2 3 4 5 6 7

7. Your handling of problems in your life. 1 2 3 4 5 6 7

8. What you are actually accomplishing in your life. 1 2 3 4 5 6 7

9. Your physical appearance - the way you look to others. 1 2 3 4 5 6 7

10. Your self. 1 2 3 4 5 6 7

11. The extent to which you adjust to changes in your life. 1 2 3 4 5 6 7

12. Your life as a whole. 1 2 3 4 5 6 7

13. Overall contentment with your life. 1 2 3 4 5 6 7

14. The extent to which your life has been what you wanted. 1 2 3 4 5 6 7

page 8 of 8© Dr. Lauren Nappen | Original Medicine, 2015 [personalhistory _2017] • www.drlaurennappen.com • 215-794-0606

Cancellation Policy

Thank you in advance for respecting and cooperating with the 24-hour cancellation policy in place. Should you be unable tocomply you will be billed for the scheduled service in full, regardless of the payment plan you are on. I do understand when lastminute conflicts occur, the occasional momentary lapse of memory, and even the ‘cell phone malfunction,’ however when thisbecomes a habit it places a strain on your care, my time and the flow of the office.

You may call the office directly or text the office cell phone (215.815.2729) to re-schedule or change your appointment.

Cell Phone Etiquette

The office cell phone is available for texting purposes only as well as the occasional and true emergency.

Texting at midnight does not constitute 24 hours.

Texting does not mean you will get an immediate response. I will do my best to accommodate your request as soonas I am able. Please be mindful that I am serving other people as well as living my life.

Please do not use this form of communication for a long synopsis of what is happening in your life.You may schedule a Certainty Session or private consultation for this.

Insurance

The care offered in this office is designed to empower how you live this life. Your active participation in this process, includingpaying for your care, is vital to your success as you reach for a greater experience of vitality. My goal is to see you blossom andprosper with as much grace and ease as possible.

All services in this office are directly charged to you and are your personal responsibility to handle at the time of service. Yourinsurance company will reimburse you to the limits of the policy you have purchased. Most policies come with extremely highdeductibles as well as higher specialty co-pays which often make seeking reimbursement mute.

As a courtesy, your insurance company will be billed electronically at the end of each month with all necessary diagnosis thatrelate to the scope of this practice and any symptoms you may present with. Insurance is structured around medically necessarycomplaints and from a chiropractic standpoint, are limited to musculoskeletal issues that can be fixed within a certain numberof visits. They may also require a continuous stream of reports documenting your progress and your prognosis. This office willnot engage in report writing of any kind nor will it fudge any records so reimbursement can be achieved.

Client Name: Date:

Client Signature:

Witness: Date: