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DAVID E. TEITELBAUM, D.O., P.A.AcupunctureProlotherapy4455 Camp Bowie Blvd #214Fort Worth, Texas 76107Osteopathic ManipulationPhone: (817) 335-4220Fax: (817) 335-3171Name: Phone(s):Phone at which you would like to receive appointment reminders:Address: City: State: Zip:Date of Birth: Age: SS#: Driver’s Lic #:Who referred you? Family Physician:Sex: M / FMarital Status: S M D WDo you have Medicare? Y / NOccupation: Employer Name:Address: City: State: Zip:Work phone:Emergency Contact: Phone:Responsible Party for Billing: Phone:Address: City: State: Zip:If insurance is in your spouse’s name: Name:SS#: Work phone and address:Dr. Teitelbaum often has medical students training under him. If you would prefer not to have a medical studentpresent during your visit, please check here:1

I hereby authorize David E. Teitelbaum, D.O. to release any information acquired in the courseof my examination and treatment.I hereby authorize any physician, hospital or medical care facility to provide all information onmy medical history and treatment to include xray reports or films to David E. Teitelbaum, D.O.I hereby authorize David E. Teitelbaum, D.O. to receive the payment directly for the surgicaland medical benefits, if any, otherwise payable under the terms of my insurance contract/policy.I herby authorize photocopies of this form to be as valid as the originals.Patient SignatureDateAuthorized SignatureDate2

DAVID E. TEITELBAUM, D.O., P.A.AcupunctureProlotherapy4455 Camp Bowie Blvd #214Fort Worth, Texas 76107Osteopathic ManipulationPhone: (817) 335-4220Fax: (817) 335-3171Welcome to our practice! Please answer all of the following questions to help us serve youmore efficiently.NAME: DATE:Please describe each of your main complaints. Include date of onset and what has happenedsince that time. (Continue on the back of this page if needed.)If any of your main complaints are work related, auto accident related or injury related, pleasedescribe in detail how the accident happened, giving dates, times and events.3

Please list any treatments (including home remedies) and surgeries that you have tried so far.Indicate if they have helped, had no effect on, or worsened your condition.Describe any disability that has resulted from your main complaints relative to your work,social life, home life or leisure activities.Have you had Xrays, MRI, etc.?Yes / NoWhen? Where?Please list all medications you are currently taking and the reasons for taking them. Includevitamins, aspirin, Tylenol, birth control, laxatives, antacids, etc.Please list all allergies:Please list all surgeries with dates:4

Describe any other serious illnesses you have had in the past 2 years not already listed withyour main complaints:Do you have any worries (legal, financial, personal) that might be affecting your health?Do you have a source of spiritual strength that you turn to in times of trouble?Do you exercise regularly? Yes / NoHow? How often?Do you sleep well? Yes / NoDo you awaken refreshed?Yes / NoDo you have a history of drug, alcohol, or substance abuse? Yes / No Describe:Do you drink alcoholic beverages? Yes / NoAmount per week:Number of sodas per week: Diet RegularDo you now, or have you ever smoked? Yes / No How many years?8

After careful consideration, please check all of the following that apply to you:I.Symptoms:Eye or vision problemsSensitive to bright light,sound, wind, odorsTension or pain in shoulders,neck, and upper backNervous, irritable, shorttemperedHeadachesMigrainesWeak or brittle nailsTraits:Feel confident, act assertivelyAmbitious and enjoy being competitiveOpenly discuss my abilities and achievementsComfortable with challenges, conflict orpressureDifficulty sleepingCold hands and feetEnjoy being first, best, unique, even outlandishComfortable directing or leading othersFollow my own hunchesFeel right, even if others disagree or disapproveII.Symptoms:Anxiety, nervousness, ordreadSensitive to heat and coldHot flashesRestless and excitableCrave cool drinks and spicyfoodsSores of mouth and tongueTraits:Enjoy the pleasure my sensesEasily know what another thinks and feelsEnjoy physical contact and emotional intimacyEnjoy excitement and stimulationEasily share my innermost feelings and desiresEasy blushingBurning sensationsHeart or circulationproblemsGet involved easily, enjoy being movedemotionallyOptimistic and hopeful despite what others maysayEasily show affection, enthusiasm andexcitementIII.Symptoms:Difficult bowel movementsSlow digestion or indigestionLoose stool or diarrheaFrequent gas or bloatingWater retention, puffinessDifficulty focusing,distractibleIrritable BowelTraits:Agreeable and accommodatingNurturing and supportive, putting others needsfirstEnjoy frequent socializing with friends andfamilyEnjoy being relied upon for reassurance and helpUlcersSensation of heaviness in thehead, body, and limbsInvolved in other people’s livesLike to create a comfortable environment forothersLoyal and accessible to friends, family, and coworkersLike getting close and being needed5

IV.Symptoms:Coughing, sneezingRespiratory allergiesRunny nose or stuffy sinusesFrequent or lingering colds,coughs, sore throatThyroid problemsFrequent phlegmShortness of breath orwheezing from exertionAsthmaBronchitisTraits:Prefer a neat and orderly lifestyleCommitted to high moral principles and conductMeticulous, tasteful and discriminatingSelf-contained, not overly involved in others’affairsDryness or tightness ofmucous membranes or skinSkin rashes, eczema, orhivesSkin growths, acneWilling to accept the authority of those withmore competenceEnjoy solving puzzles and mysteriesVirtue and principle before pleasure andfulfillmentLike things to run calmly and smoothlyV.Symptoms:Ear or hearing problemsDark rings under eyesDiminished libidoFrequent or difficulturinationKidney or bladder problems,infectionsStiffness of spine and jointsRecurring low back painHair loss or prematuregrayingTraits:Cautious and sensibleParticularly enjoy solitudeTend to keep feelings, thoughts and opinions tomyselfDon’t mind being considered unusual oreccentricLack of stamina andenduranceNeed to sleep a lotApathy, low motivationMental dullnessExcited by intellectual pursuitsCareful about what I reveal to other peoplePreferably self-sufficient and independentCherishing privacy and a few good friends6

DAVID E. TEITELBAUM, D.O., P.A.Osteopathic ManipulationAcupuncture4455 Camp Bowie Blvd #214Fort Worth, Texas 76107ProlotherapyPhone: (817) 335-4220Fax: (817) 335-3171OUR OFFICE POLICIESPlease complete and sign all of our forms and bring them with you to your appointment. Wewould appreciate your arrival 20 minutes prior to your appointment to give us sufficient timeto process all of your information.INSURANCE:NOTE: Our office does not file insurance on group or private plans. We do, however,provide you with a superbill which you may use to file for reimbursement with yourinsurance carrier.NOTE: We do accept and file Medicare claims and Medicare secondary insurances only.Remember to bring your Medicare card and your Medicare supplemental insurance cards. Ifyou have Medicare, it is your responsibility to pay for any deductible amount, co-insurance,non-covered services, or any other balance not paid by your insurance company.To keep our fees as low as possible, it is our policy to collect for services at the end of eachappointment, unless you have Medicare. For your convenience, we accept payment byMastercard, Visa, and Discover, American Express and personal checks. We do not acceptpost-dated checks.Medical insurance usually reimburses well for office visits and Osteopathic manipulativetreatments. Reimbursement for Acupuncture, Prolotherapy, and Spinal Decompression varieswidely.MISSED APPOINTMENTS:Please recognize that an appointment cancelled at the last minute results in a lost opportunityfor another patient to see us. We therefore require 24 hours advanced notice for cancellation.Patients who do not cancel an appointment 24 hours in advance will be billed for the entireamount of that appointment. Exceptions will be made for emergency situations.I have read the above and understand Dr. Teitelbaum’s office policies.Signed: Date:9

DAVID E. TEITELBAUM, D.O., P.A.Osteopathic ManipulationAcupuncture4455 Camp Bowie Blvd #214Fort Worth, Texas 76107Drdavt@sbcglobal.netProlotherapyPhone: (817) 335-4220Fax: (817) 335-3171NOTICE OF PRIVACY PRACTICESThis 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.When it comes to your health information, you have certain rights. This section explains your rights and some of ourresponsibilities to help you.Get a copy of your medical record You can ask to see a copy of your medical record and other health information we have about you. Ask us how to do this.We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge areasonable, cost-based fee.Ask us to correct your medical record You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.We may say “no” to your request, but we’ll tell you why in writing within 60 days.Request confidential communications You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.We will say “yes” to all reasonable requests.Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations. We are notrequired to agree to your request, and we may say “no” if it would affect your care.If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for thepurpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share thatinformation.Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask,who we shared it with, and why.We will include all the disclosures except for those about treatment, payment, and health care operations, and certainother disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge areasonable, cost-based fee if you ask for another one within 12 months.Get a copy of this privacy noticeYou can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provideyou with a paper copy promptly.Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise yourrights and make choices about your health information.