WELCOME TO OUR CLINIC - Clover Sites



WELCOME TO MY CLINIC

Dr. W. S. Jaakkola

9892 Rosemont Avenue #202, Lone Tree, Co 80124

Phone: 303-841-8227 Fax: 720-207-5955

E-mail: docjaakkola@ Web Site: ww.

Thank you for contacting my office. Please find enclosed information explaining my testing and treatment procedures as well as a fee schedule. There are also very extensive patient history forms attached. Please take the time to read them carefully and complete them as accurately as possible.

Bioscan/Biofeedback Patients: This evaluation includes approximately 10-20 different evaluations including Chiropractic, nutrition, acupuncture meridians, toxicity, organ balance, pathogens, hormones, emotions and homeopathy among others as determined by the Doctor.

Initial Bioscan evaluation approximately 90 minutes.

New Patient Workshop Workshops are conducted monthly and are included in your new patient evaluation fee. This does not apply to my out of state patients who are conducting their evaluation remotely.

See the attached Optimum Health Workshop flier for details.

Follow-up Bioscan visits approximately 30-60 minutes and are scheduled from 4 weeks to six months depending on your individual health concerns.

Remote Testing Patients

Utilizing the remote testing technique, patients can be tested without coming to the office. A report is e-mailed to you after the test is complete and your supplements are mailed the same day. Please contact the office for additional details

Procedure for new patients:

1) Return pages 6-13 of your new patient packet by fax or mail. Because we have a waiting list for our services, we require a reservation fee equivalent to the first visit evaluation fees. (currently $195). This reservation fee is non-refundable; however you can reschedule your appointment once with 48 hours notice.

2) Blood testing and /or Hormone Testing is recommended and in some cases required. Dr. Jaakkola utilizes the services of a laboratory co-op making this testing very affordable and comprehensive. Dr. Jaakkola will advise after reviewing your health history.

3) Attend the Optimum Health Workshop unless you are conducting your evaluation remotely. The fee is included in your initial reservation/evaluation fee.

4) You are ready for your initial evaluation.

I look forward to assisting you with your health concerns.

Sincerely,

Dr .W.S.Jaakkola D.C.

Please return pages 6-13 of the new patient packet which includes: 1) Patient Health History,

2) Financial Policy 3) Waiver 4) Reservation fee Also include your most recent blood tests

Other attachments: Welcome Letter About the Doctor Directions to clinic Fee Schedule

About the Doctor

Dr. W.S. Jaakkola D.C.

9892 Rosemont Avenue Suite #202, Lone Tree, CO 80124

Phone: (303) 841-8227 FAX: 720-2075955

Web site:

E-mail: docjaakkola@

Dr. Jaakkola has been in clinical practice since 1988.

His qualifications and education include:

|Moorhead State University- Bachelor of Arts Degree 1971 |

|University of Colorado- 2 years Chiropractic science prerequisites |

|Northwestern College of Chiropractic- 4 year Doctor of Chiropractic degree |

|Certification National Board of Chiropractic Examiners |

|Colorado and Montana State Chiropractic licenses |

|Advanced proficiency rating in Activator low force Chiropractic technique. |

|Certified Chiropractic Sports Physician |

|Certified Contact Reflex Analysis and Applied Nutrition |

|Fellow International Academy of Clinical Acupuncture |

|Fellow American Academy of Clinical Acupuncture |

|Colorado State Certified Chiropractic Acupuncturist |

|Advanced Postgraduate Study in Neuroemotional Technique |

|Certified Bionetic Examiner- International Academy of Bionetic Practitioners |

|Certified Nutritionist- American Health Science University and National Institute of Nutritional Education |

|Certified Lymphologist -International Academy of Lymphology |

|Advanced Postgraduate Certification in Homeopathy- British Institute of Homeopathy |

|Certified Level I-II Bioenergetic Screening- Institute of Quantum and Molecular Medicine, American Association of |

|Acupuncture and Bioenergetic Medicine |

|Completion Advanced Electrodermal Screening College - Atlanta, GA |

|Advanced Biofeedback Certification – Neurotherapy and Biofeedback Certification Board |

|Diplomat in Quantum Therapy- Neurotherapy and Biofeedback Certification Board |

|Advanced courses in Brimhall adjusting, nutrition and laser technique |

|Advanced Cold Laser Technique |

|Certified Advanced Electro Interstitial Scan System – College of International Holistic Studies |

|Advanced classes in Clinical Nutrition and Functional Medicine Diplomat Program-Texas Chiropractic College. |

|Additional postgraduate classes/ Blood Chemistry Analysis and Clinical Nutrition |

|Advanced training Zyto Biofeedback and EVOX Emotional balancing instruments. |

|Advanced Certification Hormone and Neurotransmitter Balancing- Labrix Laboratories |

|Advanced Courses in Bioenergetic Evaluation- College of BioEnergetic Medicine |

Dr. Jaakkola’s Services and Fee Schedule Effective June 1, 2015

Bioscan Initial Evaluation

Initial 90 minute appointment

(Includes one hour new patient workshop) $ 195

Workshop waived for remote evaluation patients

Bioscan 45 minute follow-up visits $ 115

Add a Chiropractic adjustment to either service above (add 15 minutes and add $49)

Nutritional supplements, homeopathy, supplies, postage/handling are always extra.

****There is a minimum charge of $140 for Bioscan appointments. This can be a combination of Bioscan, Adjustment, Detox Footbath and Supplements ******

All Chiropractic Adjustments – Adults and kids $ 59

EVOX (Emotional balancing techniques)

1/2 Hour $ 75

1 Hour $ 130

Detox Footbath approximately 25 minutes $ 40

Package of 5 @ $35 each (save $25) $175

Package of 10 @ $30 each (save $ 100) $300

Adjustment and Footbath Package (save $10) $ 89

Lab Test Review: Brief $ 15 Extensive $ 45

Phone consultations: First 3 minutes and E-mail NC

5 minute increments $ 10

Lab tests (Blood, Urine, Saliva Hormone Testing,)

Price varies with test. Inquire.

Missed Appointments (24 hours’ notice required) Equivalent to the service missed as listed above.

A current credit card must be on file for remote testing and purchase of supplements by phone or e-mail.

Prices subject to change without notice

Directions to My Clinic

9892 Rosemont Avenue #202 Lone Trees. CO 80124

Directions: From I-25

From I-25 go 1 mile west on Lincoln Avenue past the S. Yosemite St. Intersection.

Take your first right by the Clock Tower Building which houses a Dental office and Veterinary Clinic. Take the circle drive to the back of this building. My office is the first building on your right. Pull into the parking lot on the upper level and walk across the walking bridge to my front door.

Directions: From Quebec St. and Lincoln Avenue

Take Lincoln Avenue east and turn left on Rosemont Avenue by the Veterinary Clinic.

Travel about one block and enter the circle drive on your right. My office is the first building on your left. You must go past the building, turn left into the parking lot on the upper level, and walk across the walking bridge to my front door.

Next Optimum Health Workshop

To be announced

Limited to 10 Participants per workshop

New patients:

Included in your initial evaluation fee.

Current and past patients fees:

Complimentary

Others interested in finding out more about my clinic and techniques: $10 fee to cover materials

Topics include:

How does the Bioscan detect imbalances in the body?

What causes the body to go out of balance and become diseased?

Possible causes and prevention of cancer and autoimmune diseases.

How does the body heal?

Why won’t some conditions respond to treatment?

Why can’t I get well!!

What’s your health status.. In 80% of heart attacks the first symptom is death!

The difference between Western and Eastern medicine

Why symptoms and standard lab tests are not good indicators of your health

The Detox System………. Why is it so important to your health?

What techniques are used to balance the body?

What can I do to make our family healthier and prevent serious disease?

How do I build my immune system?

And more………..

Patients who have attended the workshop are the best informed, adopt the changes necessary to make positive changes in their lives and get well the fastest!! See you there!

Dr. W. S. Jaakkola DC

9892 Rosemont Avenue #202

Lone Tree, CO 80124

303-841-8227

Email: docjaakkola@

Web Site:

Patient Health History

Name: ________________________________________________________ Date: _____________________

Address: ____________________________________________City_______________________State________ Zip___________

Phone: Home: __________________________ Work ____________________________ Cell ____________________________

Date of Birth: _________________Age________ Height: _______ Weight: _______ Occupation:___________________________

Marital Status: Married Single Divorced Widow(er) # Children_________ Ages: ________________________

E-mail: _________________________________________________________ Referred by:____________________________

Emergency Contact: _______________________________________________________ Phone: _______________________

Current other health care providers: (circle) Chiropractor Medical Doctor Massage therapist Acupuncturist Nutritionist Bioscan Other :________________________________________________________________________________

Please list your top 5 health concerns in order of importance: How long have you had it? 1)__________________________________________________________________________________________________________

2)__________________________________________________________________________________________________________

3)__________________________________________________________________________________________________________

4)__________________________________________________________________________________________________________

5)__________________________________________________________________________________________________________

Surgeries: Year of Surgery:

1) _________________________________________________________________________________________________________ 2) _________________________________________________________________________________________________________

3) _________________________________________________________________________________________________________

4) _________________________________________________________________________________________________________

Current Medications and reason for use (e.g. blood pressure, cholesterol): How long have you been taking it? 1) _________________________________________________________________________________________________________

2) ________________________________________________________________________________________________________

3) _________________________________________________________________________________________________________

4) ________________________________________________________________________________________________________

5) _________________________________________________________________________________________________________

Women: Are you on the birth control pill or hormone replacement therapy? Yes No

If yes, what are you taking? ___________________________________________________________________________________

Nutritional Supplements you are taking:

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you use or regularly eat the following? (How often D=Daily W=Weekly M=Monthly)

Tea ______ White Flour ______ Fried foods ______ White sugar ______ Chocolate _______ Desserts ______

Sodas ______ Tobacco _______ Coffee ______ Alcohol ______ Street drugs _______ ____________________________________________________________________________________________________________

Doctor’s Notes: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Number of glasses of Water per day__________

Number of exercise sessions per week 20 minutes or more (not work) (circle) 1 2 3 4 5 6 7

What kind of exercise? _______________________________________________________________________________________

Dental: #Metal Fillings: _______ # Root Canals _______ # Crowns_______ Were your Wisdom Teeth removed? Yes No

Allergies? List ______________________________________________________________________________________________

Unresolved emotional issues: (emotions can make you sick, please be specific and explain)

Relationship(s) ___________________________________________________________________________________________

Job _________________________________________________________________________________________________

Family _________________________________________________________________________________________________

Money _________________________________________________________________________________________________

Illness _________________________________________________________________________________________________

Other ____________________________________________________________________________________________________

Number of extreme toxic exposures (radiation, insecticides, chemicals) per year __________

Explain: ________________________________________________________________________________________________

Major injuries in your life (broken bones, concussions, severe cuts, etc) What/when?

1) _____________________________________________________________________________________________________

2) ______________________________________________________________________________________________________

3) _______________________________________________________________________________________________________

Major infections in your life (e.g. Pneumonia/bronchitis, mono, Cancer, etc) What/when?

1) _______________________________________________________________________________________________________

2) ________________________________________________________________________________________________________

3) _________________________________________________________________________________________________________

Travel outside the country? Where? ___________________________________________________________________________

Vaccinations: (circle) Childhood DPT MMR Polio Small Pox Hepatitis Flu Military Series

Other: ___________________________________________ Any bad reactions? _________________________________________

Childhood diseases (circle):

Measles Mumps Rubella Chicken Pox Whooping cough Meningitis Scarlet fever

History of infections (circle):

Yeast/Candida Parasites Herpes Hepatitis Sexually Transmitted Dis. Mononucleosis

When: ______________________________________________________________________________________________________

Family History (circle) : Who? P= Parent G=Grandparent S=Sibling

Heart disease _______ Diabetes _______ Allergies _______ Multiple Sclerosis ______ Arthritis _______ Parkinson’s _______ Alzheimer’s _______ Thyroid disease ______ Circulatory _______ Alcoholism _______ Drug abuse _______ Osteoporosis ______ Asthma _______ Lupus _______

Cancer: ________ type ________________________________

Doctor’s Notes:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Health Survey Dr. W. S. Jaakkola DC

Patient: _________________________________________ Date: ________________

Please “x” the appropriate number “1-3” on the questions below. Leave blank if it does not apply.

1= mild 2=moderate 3=severe

|Category I | | |Category V | |

|CLN | | |BIL | |

|Feeling that bowels do not empty completely |1 2 3 | |Greasy or high-fat foods cause distress | 1 2 3 |

|Lower abdominal pain relief by passing gas or stool |1 2 3 | |Lower bowel gas and bloating hours after eating | 1 2 3 |

|Alternating constipation and diarrhea |1 2 3 | |Bitter metallic taste in mouth especially in morning | 1 2 3 |

|Diarrhea |1 2 3 | |Unexplained itchy skin | 1 2 3 |

|Constipation |1 2 3 | |Yellowish cast to eyes | 1 2 3 |

|Hard, dry or small stool |1 2 3 | |Stool color - clay colored to normal brown | 1 2 3 |

|Coated or “fuzzy “ tongue |1 2 3 | |Reddened skin, especially palms | 1 2 3 |

|Pass large amounts of foul smelling gas |1 2 3 | |Dry or flaky skin or hair | 1 2 3 |

|More than 3 bowel movements daily |1 2 3 | |History of gallbladder attack or stones | 1 2 3 |

|Use laxatives frequently |1 2 3 | |Have you had your gallbladder removed? | YES NO |

| | | | | |

| | | | | |

|Category II ST/ | | |Category VI | |

|hypo | | |BS/HG | |

|Excessive belching, ,burping or bloating |1 2 3 | |Crave sweets during the day | 1 2 3 |

|Gas immediately following a meal |1 2 3 | |Irritable if meals are missed | 1 2 3 |

|Offensive breath |1 2 3 | |Depend on coffee to keep going or get started | 1 2 3 |

|Difficult bowel movements |1 2 3 | |Get lightheaded if meals are missed | 1 2 3 |

|Sense of fullness during and after meals |1 2 3 | |Eating relieves fatigue | 1 2 3 |

|Difficulty digesting fruits and vegetables |1 2 3 | |Feel shaky, jittery or have tremors | 1 2 3 |

|Undigested foods found in stools |1 2 3 | |Poor memory/forgetful | 1 2 3 |

| | | |Blurred vision | 1 2 3 |

| | | | | |

| | | | | |

|Category III ST | | |Category VII | |

|/hyper | | |BS/IR | |

|Stomach pains or aching 1-4 hrs after eating |1 2 3 | |Fatigue after meals | 1 2 3 |

|Use antacids |1 2 3 | |Craves sweets during the day | 1 2 3 |

|Feel hungry an hour or two after eating |1 2 3 | |Eating sweets does not relieve cravings for sugar | 1 2 3 |

|Heartburn when lying down or bending forward |1 2 3 | |Must have sweets after meals | 1 2 3 |

|Temporary relief from antacids, milk, food, soda |1 2 3 | |Waist measurement is larger than hips | 1 2 3 |

|Digestive problems subside with rest/relaxation |1 2 3 | |Frequent urination | 1 2 3 |

|Heartburn with spicy food ,caffeine, citrus, peppers, |1 2 3 | |Increased thirst and appetite | 1 2 3 |

|Heartburn with alcohol, chocolate |1 2 3 | |Difficulty losing weight | 1 2 3 |

| | | | | |

| | | | | |

|Category IV | | |Category VII AD/hypo| |

|SI | | | | |

|Roughage and fiber cause constipation |1 2 3 | |Cannot stay asleep | 1 2 3 |

|Indigestion /fullness lasts 2-3 hrs after eating |1 2 3 | |Crave salt | 1 2 3 |

|Pain/tenderness under left rib cage |1 2 3 | |Slow starter in morning | 1 2 3 |

|Excessive passage of gas |1 2 3 | |Afternoon fatigue | 1 2 3 |

|Nausea or vomiting |1 2 3 | |Dizziness when standing up quickly | 1 2 3 |

|Undigested food in stool, foul smelling |1 2 3 | |Afternoon headaches | 1 2 3 |

|Stool mucous-like, greasy, poorly formed |1 2 3 | |Headaches with exertion or stress | 1 2 3 |

|Frequent urination |1 2 3 | |Weak nails | 1 2 3 |

|Increased thirst and appetite |1 2 3 | | | |

|Difficulty losing weight |1 2 3 | | | |

Health Survey Dr. W. S. Jaakkola DC

Patient: _________________________________________ Date: ________________

Please “x” the appropriate number “1-3” on the questions below. Leave blank if it does not apply.

1= mild 2=moderate 3=severe

|Category IX AD/hyper| | |Category X I | |

| | | |TH/hyper | |

|Cannot fall asleep |1 2 3 | |Heart palpitations |1 2 3 |

|Perspire easily |1 2 3 | |Inward trembling |1 2 3 |

|Under high amounts of stress |1 2 3 | |Increased pulse even at rest |1 2 3 |

|Weight gain when under stress |1 2 3 | |Nervous and emotional |1 2 3 |

|Wake up tired even after 6 or more hours sleep |1 2 3 | |Insomnia |1 2 3 |

|Excessive perspiration even without activity |1 2 3 | |Night sweats |1 2 3 |

|Decreased stamina |1 2 3 | |Difficulty gaining weight |1 2 3 |

|Anxious |1 2 3 | | | |

|Irritable |1 2 3 | | | |

|Sugar cravings |1 2 3 | | | |

|Headaches |1 2 3 | | | |

|Depressed |1 2 3 | | | |

|Dizzy spells |1 2 3 | | | |

|Muscle aches and pains |1 2 3 | | | |

| | | | | |

| | | | | |

|Category X | | |Category XII PIT/hypo | |

|TH/hypo | | | | |

|Tired , sluggish |1 2 3 | |Diminished Sex drive |1 2 3 |

|Feel cold - hands, feet, all over |1 2 3 | |Menstrual disorders or lack of menstruation (women) |1 2 3 |

|Require excessive amounts of sleep to function |1 2 3 | |Increased ability to eat sugar without symptoms |1 2 3 |

|Increase in weight gain even with low calorie diet |1 2 3 | | | |

|Constipation |1 2 3 | | | |

|Depression, lack of motivation |1 2 3 | |Category XIII PIT/TH/hyper | |

|Morning headaches that wear off as day progresses |1 2 3 | |Increased sex drive |1 2 3 |

|Outer third of eyebrows thin |1 2 3 | |Tolerance to sugars reduced |1 2 3 |

|Losing hair on scalp, face or genitals |1 2 3 | |“Splitting” type headaches |1 2 3 |

|Hair dry or brittle |1 2 3 | | | |

|Nails breaking or brittle |1 2 3 | | | |

|Slow pulse rate |1 2 3 | | | |

|Dry skin or scalp |1 2 3 | | | |

|Mental sluggishness |1 2 3 | | | |

|Goiter |1 2 3 | | | |

|Hoarseness |1 2 3 | | | |

|Infertility problems |1 2 3 | | | |

|Allergies |1 2 3 | | | |

| | | | | |

Doctors Notes: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Health Survey Dr. W. S. Jaakkola DC

Patient: _________________________________________ Date: ________________

Please “x” the appropriate number “1-3” on the questions below. Leave blank if it does not apply.

1= mild 2=moderate 3=severe

|Women’s Symptom review Women’s | | |Men’s Symptom review Men’s | |

| | | | | |

|ELW | | |EDM | |

|Hot Flashes |1 2 3 | |Decreased urine flow |1 2 3 |

|Night sweats |1 2 3 | |Frequent urges to urinate |1 2 3 |

|Vaginal dryness |1 2 3 | |Prostate problems (diagnosed) |1 2 3 |

|Incontinence |1 2 3 | |Weight gain –Chest/Hips |1 2 3 |

| | | | | |

| | | | | |

|PWL/EDM | | |MS/AND L | |

|Bleeding changes |1 2 3 | |Decreased sex drive |1 2 3 |

|Uterine fibroids |1 2 3 | |Decreased erections |1 2 3 |

|Water retention |1 2 3 | |Ringing in the ears |1 2 3 |

|Tender breasts |1 2 3 | |High cholesterol |1 2 3 |

|Fibrocystic breasts (lumps) |1 2 3 | |Elevated Triglycerides |1 2 3 |

|Increased forgetfulness |1 2 3 | |Decreased mental sharpness |1 2 3 |

|Foggy thinking |1 2 3 | |Increased forgetfulness |1 2 3 |

|Tearful |1 2 3 | |Decreased muscle size |1 2 3 |

|Depressed |1 2 3 | |Decreased flexibility |1 2 3 |

|Mood swings |1 2 3 | |Sore muscles |1 2 3 |

| | | |Increased joint pain |1 2 3 |

| | | |Bone loss (from x-ray or bone scan results) |1 2 3 |

|MS/AND H | | | | |

|Acne |1 2 3 | |Rapid aging |1 2 3 |

|Increased facial/body hair |1 2 3 | |Thinning skin |1 2 3 |

|Hair loss on scalp |1 2 3 | | | |

|Weight gain- hips |1 2 3 | | | |

|Weight gain- Waist |1 2 3 | |Category XIV (Males only) PRST |1 2 3 |

|High Cholesterol |1 2 3 | |Urination difficulty or dribbling |1 2 3 |

|Elevated Triglycerides |1 2 3 | |Frequent urination |1 2 3 |

| | | |Pain inside of legs or heels |1 2 3 |

| | | |Feeling of incomplete bowel evacuation |1 2 3 |

|AND L | | | | |

|Decreased sex drive |1 2 3 | |Legs nervous at night |1 2 3 |

|Decreased muscle size |1 2 3 | | | |

|Thinning skin |1 2 3 | | | |

|Ringing in ears |1 2 3 | | | |

|Bone loss |1 2 3 | | | |

| | | | | |

Doctors Notes: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Health Survey Dr. W. S. Jaakkola DC

Patient: _________________________________________ Date: ________________

Please “x” the appropriate number “1-3” on the questions below. Leave blank if it does not apply.

1= mild 2=moderate 3=severe

|SECTION A -GBF | | |Section 1-S (continued) | |

|Is your memory noticeably declining |1 2 3 | |Feelings of paranoia |1 2 3 |

|Hard time remembering names/phone numbers |1 2 3 | |Losing enjoyment for your favorite foods |1 2 3 |

|Is your ability to focus noticeably declining |1 2 3 | |Have feelings of dependency on others |1 2 3 |

|Has it become harder for you to learn things |1 2 3 | |Feel you lack artistic appreciation |1 2 3 |

|Hard time remembering your appointments |1 2 3 | |Feel depressed in overcast weather |1 2 3 |

|Is your temperament getting worse in general |1 2 3 | |Losing your enthusiasm for your favorite activities |1 2 3 |

|Are you losing your attention span |1 2 3 | |Feel more susceptible to pain |1 2 3 |

|Find yourself down or sad |1 2 3 | |Have difficulty falling into deep restful sleep |1 2 3 |

|Fatigue faster when driving compared to the past |1 2 3 | |Have feelings of unprovoked anger |1 2 3 |

|Fatigue faster when reading compared to the past |1 2 3 | |Losing your enjoyment of friends and relationships |1 2 3 |

|Walk into rooms and forget why |1 2 3 | | | |

|Pick up your cell phone and forget why |1 2 3 | |Section 2 - D | |

| | | |Have feelings of hopelessness |1 2 3 |

|Section B -STR | | |Have self-destructive thoughts |1 2 3 |

|How high is your stress level |1 2 3 | |Have an inability to handle stress |1 2 3 |

|Feel that you have something that must be done |1 2 3 | |Have anger and aggression while under stress |1 2 3 |

|Do you feel you never have time for yourself |1 2 3 | |Feel you are not rested even after long hours of sleep |1 2 3 |

|Feel you are not getting enough sleep or rest |1 2 3 | |Prefer to isolate yourself from others |1 2 3 |

|Do you find it difficult to get regular exercise |1 2 3 | |Unexplained lack of concern for family/friends |1 2 3 |

|Do you feel uncared for by the people in your life |1 2 3 | |Easily distracted or inability to finish tasks |1 2 3 |

|Feel you are not accomplishing your life’s purpose |1 2 3 | |Feel the need to consume caffeine to stay alert |1 2 3 |

|Sharing your problems with someone is difficult |1 2 3 | |Have frequent feelings of worthlessness |1 2 3 |

| | | |Feel a decrease in your libido |1 2 3 |

|Section C 1- SB | | |Lose your temper for minor reasons |1 2 3 |

|Depend on coffee to keep yourself going |1 2 3 | | | |

|Get irritable, shaky, or lightheaded between meals |1 2 3 | | | |

|Do you feel energized after eating |1 2 3 | |Section 3 - G | |

|Difficulty eating large meals in the morning |1 2 3 | |Feel anxious or panic for no reason |1 2 3 |

|Energy level drops in the afternoon |1 2 3 | |Have feelings of dread or impending doom |1 2 3 |

|Crave sugar and sweets in the afternoon |1 2 3 | |Feel knots in your stomach |1 2 3 |

|Wake up in the middle of the night |1 2 3 | |Feelings of being overwhelmed for no reason |1 2 3 |

|Have difficulty concentrating before eating |1 2 3 | |Feelings of guilt about everyday decisions |1 2 3 |

|Feel agitated, upset, and nervous between meals |1 2 3 | |Mind feel restless |1 2 3 |

| | | |Hard to turn your mind off when you want to relax |1 2 3 |

|Section C 2-IR | | |Wandering attention span |1 2 3 |

|Crave sugar and sweets after meals |1 2 3 | |Worry about things for no reason |1 2 3 |

|Feel you need stimulants such as coffee after meals |1 2 3 | |Feelings of inner tension and excitability |1 2 3 |

|Have difficulty losing weight |1 2 3 | | | |

|Waist girth is larger than your hip girth |1 2 3 | |Section 4 – ACH | |

|Urinate frequently |1 2 3 | |Feel your visual memory (shapes/images)decreased |1 2 3 |

|Thirst and appetite have increased |1 2 3 | |Memory lapses |1 2 3 |

|Weight gain when under stress |1 2 3 | |Creativity has decreased |1 2 3 |

|Difficulty falling asleep |1 2 3 | |Comprehension/ability to understand has decreased |1 2 3 |

| | | |Difficulty calculating numbers |1 2 3 |

|Section 1-S | | |Difficulty recognizing objects & faces |1 2 3 |

|Losing your pleasure in hobbies and interests |1 2 3 | |Feel like your opinion about yourself has changed |1 2 3 |

|Feel sad or down for no reason |1 2 3 | |Experiencing excessive urination |1 2 3 |

|Feel like you are not enjoying life |1 2 3 | |Slower mental response/hard to think of words |1 2 3 |

|Feelings of inner rage (anger) |1 2 3 | | |1 2 3 |

Financial Policy

Insurance companies label the Biofeedback service as “elective” and generally will not cover this service. They generally pay for Chiropractic related services if your policy covers that benefit. We do not bill insurance companies or write insurance reports. For in-clinic services, you may request an insurance form at the end of your visit. You may submit your claim yourself if your coverage allows. We accept cash, checks, and MasterCard/Visa.

Cancellation Policy

Twenty-four (24) hours notice of cancellation or rescheduling an appointment is required to avoid a missed appointment charge.

Services are billed at their regular rate as shown on the current fee schedule. The credit card on file will be billed for these services immediately following the missed appointment. An e-mail or text message will serve as a reminder notice if your information is provided. This is a courtesy and should not be construed as a requirement by the clinic for you to show up to your appointment.

I understand and will abide by the financial policy above:

X___________________________________________ X __________________

Client’s Signature Date

Fees: Initial visits/ remote testing/ missed appointments/ ordering nutritional supplements.

A valid credit card is required to be on file for scheduling the initial evaluation, remote evaluations, missed appointment charges and purchasing supplements which are mailed or picked up in person at the clinic and not paid by cash or check. So Dr. Jaakkola is not interrupted during regular patient visits, please no walk- ins to order supplements. Orders called in or e-mailed will be available or mailed within 1 business day.

Name on credit card: __________________________________________________________

Billing Address: _____________________________________City __________________State_________ Zip _______

Card # ________________________________________________ Expiration ______/_____

3 Digit Security code on back of card _______________

For appointment reminders: Cell phone: _________________ e-mail ____________________________

I authorize the clinic to bill my credit card listed above for scheduled appointments, remote testing fees, missed appointment fees, and for nutritional supplements and supplies which I order by phone or e-mail.

Signature of Cardholder X_______________________________ Date X______________

DISCLAIMER\WAIVER

Dr. W.S. Jaakkola D.C.

1) Dr. Jaakkola is not an allopathic physician (M.D.) He does not perform surgery, prescribe drugs nor practice psychiatry\psychology. Dr. Jaakkola is a Doctor of Chiropractic, a primary health care provider trained in the art and science of natural health care.

2) I understand Dr. Jaakkola provides this health care according to state and national scope of practice guidelines.

3) The services provided by Dr. Jaakkola may not be understood nor accepted by allopathic physicians

or other health care professionals however, the evaluation and treatment methods Dr. Jaakkola uses are used effectively throughout the world.

4) Dr. Jaakkola is in no way encouraging me to terminate any medications or therapies which have

been prescribed for me by other health care practitioners.

5) Dr. Jaakkola is not using the Biofeedback instrument to diagnose or treat cancer or any other

disease. The instrument is being used to provide information to assist in restoring natural balance to the body

and therefore promoting optimum health and wellness.

6) If Dr. Jaakkola feels my condition would respond better to another type of therapy I understand he will make the

appropriate referral.

7) I understand, as with any health care therapy there is no guarantee of results.

8) If I am the legal guardian of a minor or person deemed incompetent, I affirm I am legally and totally responsible

for them and act in their best interest in authorizing their evaluation and subsequent treatment.

I have read, understand and agree with the above and acknowledge so by my signature. I hereby consent to the evaluation and subsequent treatment.

Signature of Patient or Guardian X _____________________________________________________________

_____________________________________________________________________________________________

HIPAA Statement:

The protection of your health records is a high priority in our office. We therefore do not participate in the electronic transmission of records or share your information with anyone without your permission. Your signature is required to send records to health care providers or insurance companies. You will be given a specific HIPPA form to sign prior to release of information.

I understand the HIPPA Statement Above:

Signature of patient or Guardian: X________________________________ Date: X_______________

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