New Patient

Please fill out the following questionnaire and fax, mail or bring to your appointment.

Upon completing this extensive questionnaire the doctor will analyze the information and will provide a consultation that usually runs fifteen minutes to a half an hour. Following this a comprehensive examination. This exam generally runs between one hour and one and a half hours. It includes orthopedic tests, applied Kinesiology muscle testing, vital signs and neurological testing where applicable. Vitamin and mineral testing,.  

Along with a urinalysis that reveals possible vitamin, mineral or enzyme deficiencies, digestive disorders, bowel toxicity, adrenal stress, electrolyte imbalances and kidney or liver stress. Following these first two steps the doctor will outline his report of findings with his recommendations.

The recommendations are divided into five categories. 1. Water and fluids 2. Whole foods 3. Rest and relaxation i.e. biofeedback, yoga breathing meditation. progressive relaxation…  4.Education  & Ancillary treatments i.e. acupuncture, chiropractic, massage, colonic, sitz bath…. Books seminars, tapes.. 5. The mental emotional. i.e. goals, vision statement…

This questionnaire is confidential; if you have difficulty answering some questions leave it blank for the time being. If you have questions regarding this questionnaire you may bring then up at your initial consultation



Name. _______________________________ Phone #. ___________ Work Phone__________________

Date Of Birth________ M__ F___ Height ______ Weight_____Marital Status_____________________

Mailing Address_________________ SS# ______________ Who Referred You To Dr Cola____________

email address ___________________________________

1. What is your primary reason for contacting Dr. Cola? Please describe this in detail.




2. What do you believe is contributing to this? Or what do you believe to be the cause?




3. Is your overall health-getting better or worse? Please explain.




4. List things that you are presently doing that are health promoting.



5. Please list stressful areas in your life. (Present and past)





6. Please list any secondary health concerns.




7. Please list any medications you are presently taking



8. Please list any over the counter med's or vitamins or other supplements



9. Please list amounts of coffee, tea or alcohol consumed each day or week.


Are you seeking any help from other physicians for these conditions Medical doctor, chiropractor,
acupuncturist, naturopath? Circle.

Health History

Please indicate if there is a family history to any of the following conditions.
Please circle: High blood pressure, heart attack, emphysema, seizures-convulsions, HIV positive, asthma,
diabetes, kidney disease, ulcer or stomach problems. Stroke, arthritis-rheumatism. Mental illness,
thyroid disease, circulation problem, cancer, alcoholism.
Any other_____________________________________________

Do you smoke? Past or present? Circle. If yes how many packs and how long?



What operations have you had? What year? Include Dental Work & .# Of Cavities.




Was your birth a natural one? If not describe the medical intervention. I.e. c-section, forceps, epidural,



Where you breast-fed as an infant? How long?



15.For women. Do you take birth control pills? Past or present? How long?


List the all foods you crave. i.e. salty, greasy, dairy etc.

17.How many times in the last five years have you used antibiotics?

     10 or more      5 to 9          5 to 1           not at all
How many times in your life have you taken antibiotics?

     10 or more     5 to 9          5 to 1           not at all
How many times each week do you have desert with refined white sugar?

     7 or more     3 to 6          1 to 2           not at all
How often do you eat white flour
     7 or more     3 to 6           1 to 2          not at all

Do you get up in the middle of the night to urinate or have a bowel movement?

22. Have you taken cortisone, prednisome or any other steroid?

Do you have headaches or migraines? If yes please give details.

Do you have asthma or allergies?

Is your tongue coated?

Do you exercise? If yes how often…

26. How many hours of sleep do you get each night?

How much do the following contribute to your health?  1. Very little, if any     10. Absolutely

Consumption…diet                        1--------------5------------10
Relationships/ Friends/ Family     1--------------5------------10
Rest/ Relaxation                             1--------------5------------10
Genetics                                          1--------------5------------10
Luck                                                 1--------------5------------10
Your doctor                                      1--------------5------------10
Spirituality/ Belief/ Faith                 1--------------5------------10
Medicine                                         1--------------5------------10
Sanitation/ Hygiene                       1--------------5------------10

Doing and Being Self-Assessment;
1 - lacking                                 10 - fulfilling

Physical Health                            1---------------5----------------10
Mental/ Emotional Health           1---------------5----------------10
Relationships                               1---------------5----------------10
Career/ Contribution                   1---------------5----------------10
Financial Freedom                      1---------------5----------------10
Creative/ Fun                               1---------------5----------------10

Oxidative Typing Questionnaire.

27. Frequency of bowel movements: How Many Bowel movements do you have a day ____.


28. Do you have a history of constipation or diarrheas. Please circle.

29. Laxative use. Past or present. Please circle.

If yes please describe type used and frequency._____________________.
________________________________________________________.


Numbers, which apply to you, enter 1,2, or 3.
For mild symptoms (occur once or twice a year)
For moderate symptoms (occur several times a year)
For severe symptoms (you are aware of it almost constantly).
Leave blank if question or statement does not apply to you.

Stool Odor.    _____. Offensive.      Stool color, _____Medium Brown.          
_____. Little odor.                         _____Dark Brown
_____. No odor.                            _____Black.
Intestinal Gas._____. Daily.                                 _____Blood visible.
          _____. With certain meals.                        _____Mucus visible.
          _____. Painful.                                             _____Greasy
          _____. Foul smelling.                                  _____Yellow               
Stool Consistency:                                                 _____Greenish      
          _____. Large and Hard                          _____Clay colored
          _____. Small and Hard.                          _____Varies.     
          _____. Visible undigested foods.          _____. Often Float.     
          _____. Difficult to pass.
          _____. Loose, but not diarrhea.
          _____. Thin, ribbon like.
          _____. Alternate between hard and watery.      
          _____. Large well formed. (3 fingers wide. 6” in length)
          _____. Medium well formed (2 fingers wide 4-6” in length
30. Do you have abdominal pain that is relieved with a bowel movement? _____.

31. Have you ever been diagnosed with a gastrointestinal illness? _____.


32. Have you had or do you have hemorrhoids or varicose veins? Explain

33. Do you need to wear sunglasses outdoors?


Detoxification Assessment.

33. Are you or have you in the past been 20 pounds or more overweight?

34. Have you ever been diagnosed with having gallstones?

35. Past or present heavy alcohol consumption.


36. History of synthetic steroid use. 1. Anabolic. 2. Estrogen. 3. Oral Contraceptives. Please circle, and state duration. Dates: From: __________ To: ___________


37. Past or present exposure to cleaning solvents, pesticides, antibiotic, diuretics, thyroid hormones, Nonsteriodal anti-inflammatory drugs. Explain.



38. Do you ever get unexplained pains on your right side?


39. Does alcohol consumed in small amounts cause you problems?

40. Does exposure to cigarette smoke cause you problems?

41. Does caffeine consumption not agree with you?

42. Do you get any burning or irritation during or after urination?

43. Does your urine have a strong odor to it?


44. Is your urine ever, Cloudy, orange, red, brown, or. greenish. Please circle and explain.

45. Do you have difficulty perspiring?

46. Do you perspire excessively?

47. Does your perspiration have a strong smell?

Do your feet perspire or have a strong smell?


48. Explain the type(s) of water you have consumed in the past and present. I.e. city water, well water, filtrated, spring, distilled.

49. Do you ever experience pain that awakes you from a sound sleep? Past or present

50. Do you ever experience night sweats  Past or present?

















Symptom Survey

Enter 1 for mild symptoms (occur once or twice a year)
Enter 2 for moderate symptoms (occur several times a yeay)
Enter 3 for severe symptoms (you are aware of it almost constantly
Enter P for symptoms experienced in the past

Category 1
1.___ Acid foods upset
2.___ Get chilled often
3.___ “Lump” in throat
4.___ Dry mouth-eyes-nose
5.___ Pulse speeds after meals
6___ Keyed up- fail to calm
7___ Cuts heal slowly
8___ Gag easily
9___ Unable to relax
10___ Extremities cold clammy
11___ Strong light irritates
12___ Urine amounts reduced
13___ Heart pounds after eating
14___ Nervous stomach
15___ Appetite reduced
16___ Cold sweats often
17___ Fever easily raised
18___ Neuralgia-like pains
19___ Staring, blinks little
20___ Sour stomach frequent
21___ Joint stiffness after arising
22___ Muscle leg toe cramps at night
23___ “Butterfly” in stomach
24___ Eyes or nose watery
25___ Eyes Blink Often
26___ Eyelids Swollen
27___ Indigestion soon after meals
28___ Always feels hungry. Lightheaded Often
29___ Digestion Rapid
30___ Vomiting frequent
31___ Hoarseness frequent
32___ Breathing Irregular
33___ Pulse Slow. Feels irregular
34___ Gagging reflex slow
35___ Difficulty Swallowing
36___ Constipation/ Diarrhea alternating
37___ “Slow Starter”
38___ Get Chilled frequently
39___ Perspire easily
40___ Circulation Poor, sensitive to cold
41___ Subject to colds, asthma bronchitis
Category 2
42___ Eat when nervous
43___ Excessive appetite
44___ Hungry between meals
45___ Irritable between meals
46___ Get shaky if hungry
47___ Fatigue, eating relieves
48___ Lightheadedness if meals delayed
49___ Heart palpitates if meals missed or delayed
50___ Afternoon headaches
51___ Overeating sweets upsets
52___ Awaken after few hours of sleep hard to get back asleep
53___ Crave candy or coffee in afternoon
54___ Moods of depression, blues or melancholy
55___ Abnormal craving for sweets or snacks
Category 3
56___ Hands and feet go to sleep easily
57___ Sign frequently “air hunger”
58___ Aware of breathing heavily
59___ High altitude discomfort
60___ Opens window in closed room
61___ Susceptible to colds and fever
62___ Afternoon yawner
63___ Get drowsy often
64___ Swollen ankles worse at night
65___ Muscle cramps worse with exercise. Charley Horse
66___ Shortness of breath with exertion
67___ Dull pain in chest or radiating into left arm. Worse with exertion
68___ Bruise easily. Black/ Blue spots
69___ Tendency to anemia.
70___ “Nose bleeds” frequent
71___ Ringing in ear
72___ Tension or tightness under breast bone
Category 4.
73___ Dizziness
74___ Dry Skin
75___ Burning Feet
76___ Blurred Vision
77___ Itching skin and feet.
78___ Excessive falling hair
79___ Frequent skin rashes
80___ Bitter metallic taste in mouth in morning
81___ Bowel movements painful or difficult
82___ Worrier, feels insecure
83___ Feeling queasy, headache over eyes
84___ Greasy foods upset
85___ Stools light-colored
86___ Skin peels on foot soles
87___ Pain between shoulder blades
88___ Use laxatives
89___ Stools alternate between soft to watery
90___ History of gallbladder attacks or gallstones
91___ Sneezing attacks
92___ Dreaming, nightmares, Don't remember dreams
93___ Bad Breath (halitosis)
94___ Milk Products cause distress
95___ Sensitive to hot water
96___ Burning or itching anus
97___ Craves sweets
Category 5
98___ Loss of taste for meat
99___ Lower bowel gas several hour after eating
100___ Burning stomach sense eating relieves
101___Coated Tongue
102___Pass large amounts of foul smelling gas
103___ Indigestion after meals
104___ Mucus on stools
105___ Gas shortly after eating
106___ Stomach bloating after meals
Category 6
107___ Insomnia
108___ Nervousness
109___ Can't gain weight
110___ Intolerance to heat
111___ Highly emotional
112___ Flush easily
113___ Night Sweats
114___ Thin moist skin
115___ Inward Trembling
116___ Heart Palpitates
117___ Increased appetite without weight gain
118___ Pulse fast at rest
119___ Eyelids and face twitch
120___ Irritable and restless
121___ Can't work under pressure
122___ Increase in weight
123___ Decrease in appetite
124___ Fatigue easily
125___ Ringing in Ear
126___ Sleeping during day
127__ Sensitive to cold
128___Dry or Scaly skin
129___Constipation
130___Mental Sluggishness
131___Hair Coarse
132___Headache on arising wear off during day
133___ Slow Pulse below 65
134___ Frequency
135___ Impaired hearing
136___ Reduced initiative
Category 7
137___ Failing memory
138___ Low blood Pressure
139___ Increased sex drive
140___ Headache splitting type
141___ Decreased sugar tolerance
142___ Abnormal thirst
143___ Bloating of abdomen
144___ Weight gain around hips or waist
145___ Sex drive reduced or lacking
146___ Tendency to ulcers, colitis
147___ Increased Sugar tolerance
148___ Menstrual disorders
149___ Teenagers Lack of menstrual function
Category 8
150___ Dizziness
151___ Headache
152___ Hot Flashes
153___ Increased Blood Pressure
154___ Hair growth on face or body (female)
155___ Sugar in urine (not diabetes)
156___ Masculine tendency (female)
Category 9
157___ Weakness, Dizziness upon rising
158___ Fatigue
159___ Low blood pressure
160___ Nail weal\k or ridged
161___ Tendency to hives
162___ Arthritic Tendency
163___ Perspiration increase
164___ Bowel Disorder
165___ Poor Circulation
166___ Swollen Ankles
167___ Crave Salt
168___ Brown spots or bronzing of skin
169___ Allergies tendency to Asthma
170___ Weakness after colds, influenza
171___ Exhaustion, muscular or nervous
171___ Respiratory disorder
Category 10
173___ Very easily fatigued
174___ PMS
175___ Painful menses
176___ Depression PMS
177___ Excessive menses, prolonged
178___ Painful breast
179___ Menstruate to frequently
180___ Vaginal discharge
181___ Hysterectomy / ovaries removed
182___ Menopausal not flashes
183___ Menses scanty or missed
184___ Acne worse at menses
185___ Depression long standing
Category 11
186___ Prostate trouble
187___ Urination difficult or dribbling
188___ Night urination frequent
189___ Depression
190___ Pain on inside of legs or heels
191___ Feeling of incomplete bowel evacuation
192___ Lack of energy
193___ Migrating aches and pain
194___ Tire too easily
195___ Avoids activity
196___ Leg nervousness at night
197___ Diminished sex drive



AN EXERCISE IN CLARIFYING YOUR VALUES

The foundation of growth and congruency

What is the meaning of your life? What is your purpose. What are your goals, how do you want to be remembered? Why do you do your daily duties? What makes you tick? How do you make decisions?
These are crucial questions that most Americans have not answered.  Because of this lack of clarity, people struggle when faced with making choices that are consistent with growth or healing.  Answering these questions honestly is not easy to do.  Answering these questions honestly, however, will help simplify the rest of your life.  Let me explain.  When answered, these questions allow for congruency in our daily lives. We are able to identify what is important and act upon it.

For instance, most people will put health high on their list, but when we look at their behavior, their actions tell us otherwise. For instance, eating at McDonald's or other fast food twice a week, drinking sodas, eating French fries, not exercising or not getting enough rest is not congruent with valuing health.
We can apply this question to anything we profess to value, for example, family.   Now answer this - is working sixty hours a week, watching television another twenty hours, never having a sit down meal with the entire family present, etc., congruent with valuing family?  In order to continue with behaviors that are obviously at odds with values, we must rationalize or compartmentalize.  We do this to justify our actions, so that we can avoid change.  This exercise will help you eliminate this.  You will be better able to identify your inconsistencies.  You will be able to consider alternatives, which have the potential to guide you to more happiness and fulfillment.

Another empowering aspect of this exercise is that when we create a powerful why the how becomes easy. The powerful whys are your values. The meanings you attach to our life become your motivators… When you are clear on these the “how” part becomes very easy. For example a mother who instinctively values the needs of her newborn will find it relatively easy to get up several times each night.

There are no “correct” answers to value clarification. To choose not to complete this exercise is to prolong growth.
The key to this exercise is to devote quality time when asking yourself these questions, and reflect honestly upon your answers. After you have written your answers down, check to see how the daily patterns of your life support your innermost desires.  Perhaps you are sabotaging what you truly value.  Becoming aware of those patterns is the first step if you would like to change them.

As you work deeper into this exercise the goal is to search for your core values or your true values. Going to the core  means you must ask more questions. Remember when you were a kid and followed each answer your parents gave you with another “But why…”  Do it now. Why do I value health? So I can have more energy. Why do I want more energy? So I can go hiking. Why do I want to hike?  So I can be in tune with nature. Why do I want to be in tune with nature?  So I can appreciate the magnificence of our world. OR, another example could be “Why do I value health? So I can have the energy to spend with my family. Why do I want to be with my family? So I can experience kindness, acceptance and love.

What I am doing with these examples is showing the difference between an end value and a means value. Health is a means to your true value. It is the true values that we want to identify here. More examples.  Why do I want money? So I can go on vacation. Why do I want to vacation? So I can spend time with people I care about… Fun, Intimacy, Peace… So you can see again, money is the means value, helping to realize the core value which is your true meaning or purpose to your existence.

Once you have completed this exercise, congratulate yourself. You have just identified your priorities in life. These values or priorities will help and guide you through decisions of the future. The next step is learn ways to “own” these priorities.

Here is my own list of end and mean values. Feel free to personalize it.  It is within that personalization that you will come to know and appreciate who you are. Enjoy the process.

Ability                   Energy            Intimacy              Responsibility
Acceptance        Education       Integrity               Righteousness
Accuracy             Elderly            Justice                 Risk
Athletics            Discipline                                       Relationships
Achievement      Excitement      Kindness               Romance
Adventure           Faith                  Knowledge           Routine          
Altruism               Fame                Law-Abidance     Safety
Animals               Family                Love                    Security
Awareness         Forgiveness     Mastery                Self-Control
Balance              Freedom           Maturity                Self-Esteem
Beauty                Friendship          Money                 Self-interest               
Brotherhood       Fun                    Nature                  Spirituality
Comfort              Goodness         Peace                 Strength
Communication Growth             Pleasure              Success     
Compassion       Happiness       Popularity             Support     
Competence      Health               Positive        Surrender
Conquest           Honesty             Power                  Talent
Cooperation      Holiness             Prestige              Toys
Courage            Honor                  Pride                   Treasure
Creativity           Hope                   Privacy                Trust
Culture              Humility               Property              Truth
Dignity               Independence     Purpose             Wealth
Direction           Individuality         Quite                    Wisdom
Discovery         innocence           Reason               Winning
Duty                  Innovation              Revenge          Worship                 

Don't confuse this exercise with a test.  There are no right or wrong answers.  The goal is to help you discover where you are acting consistent to your values and where you are not.

Once we have identified the inconsistencies, the next step is to uncover what limiting beliefs or mental and emotional patterns are at play. I have many resources to coach you through ways to deal with limiting beliefs or mental or emotional patterns.
Following the initial exercise, I strongly encourage you to take the next step, which is a personal mission statement.  And beyond that, making a mission statement along with your family, or your relationships, and your career is just as important. Steven Covey has a two tape audio lesson that includes a workbook.  It is wonderful in its clarity on the steps to guide you in developing a mission statement, and I cannot recommend it highly enough.

Congratulations. I look forward to working with you.
Dr. Mark Colafranceschi. .

I would like to follow up with some questions to help move you to better health through self leverage.
What moved you to become a patient/ client of Dr Cola?



What would you consider a fulfilling win as a result of the care of Dr Colafranceschi?


How do you assess your present ability to function as a result of your present state of health.
please circle one
Terrible*** Poor***Sub-average*** Average*** Above-average*** Average*** Good*** Great

If you have a health issue, is it getting better or worse or remaining the same?


How do you know this?



Do you have any fears or dreads about your future health?




List proactive health choices. Thoughts behavior, exercise diet etc....



List destructive health choices






What do you believe it will take to improve your health?





How do you perceive Dr Cola's role and responsibility with respect to your health care?





How do you perceive your role and responsibility with respect to improving you health?







What do you think is your potential for health and healing?
(please close your eyes and attempt to visualize yourself as being healthy)




Do you believe you are serving a higher purpose here on earth?




If yes. What is that purpose?




What do you think stops a person from living to his or her health potential?






If Dr Cola offers you a common sense straight forward plan to achieve optimal health how committed are you on a scale of one to ten. One being not at all committed to ten being 100% commitment.______






What do you estimate your health is costing you in terms of energy, productivity, relationships, freedom, money joy or peace of mind?









What might it cost you in the future if your health continue to remain the same or decline?
(please close your eyes and visualize this)




What resources are you presently allocating to the promotion of your health?
Money, Time and energy







Do you believe there is a quick fix to your health concern?








Do you think you can be healthy without being happy?
yes or no please circle.





List any potential obstacles you may foresee in the process of achieving optimal health?

Social/ Friends

Family

Finances

Work



Because education is the cornerstone to Dr Cola's process and he is committed to providing this education to you in ways that you prefer.
How do you prefer to learn in order of priority

Reading
Listening to audio tapes
Watching videos
Seminars workshops


 It is up to you to decide just what you are going to designate towards your health.  To give you some guidelines prior to any assessment or laboratory analysis I suggest that it will require an average of one hour of your time per day dedicated to food preparation, breathing exercises, relaxation exercises, stretching, strengthening, etc.  With respect to your finances, the evaluations that will follow will be 1) initial examination, costing between 65 and 95 dollars, followed by laboratory analysis, costing between 50 to 100 dollars (usually closer to 50).  Further recommendations, treatments and ancillary care.  as you can see, will be discussed to follow.  there is a lot of time and energy which will be put forth by Dr. cola, and likewise this time and energy will be required of you.

If corrective care is not what you are looking for please indicate to the Dr. prior to the examination that you are looking for relief care. Thank You


Fee Schedule & Office Policies;

In efforts to keep our clinic functioning optimally and to insure the highest quality of service possible, we ask that you review and respect the following office policies.

Appointments:
     Appointments can be made in person or over the phone during clinic hours. We will not call patients as reminders except for follow-up exams.  Please specify treatment, if applicable, when making an appointment.  In order to better treat you, an initial exam is required for all patients.
Cancellations:
All cancellations need to be made 24 hours in advance to avoid a $20.00 cancellation fee.  Missed appointments need to be rescheduled by the patient. The clinic will not call for rescheduling of missed or canceled appointments.
Late Arrivals:
Late arrivals may or may not be admitted depending on Doctor availability.
Rentals: Our clinic offers a wide variety of tape, video, and book rentals on health and related topics.  To utilize these resources, we require a $40.00 deposit check plus rental fees.  Lost or damaged rentals will incur a replacement cost deducted from the deposit check, otherwise the check will not be cashed.
Classes: Our clinic also offers a wide variety of classes and workshops.  All classes are free of charge for teenagers.
All classes must be pre-registered by paying in advance.
Payments:
     Payments must be made in advance or at the time services are rendered. We accepts, Major Credit cards, Checks or Cash. A note on finances

Procedures                              Amount
Adjustments                                                          27-40.00
Urinalysis                                                               50.00
Nutritional Consult (phone or office)                   75.00/ half hour
4 hour Glucose tolerance Test                            35.00
Office Visit                                                            27.00
Brief Exam                                                            42-55.00
Comprehensive Exam                                        95-130.00
Office Visit after hours                                        75.00
Acupuncture                                                         referred
Muscle Test                                                          25.00
Kinesiology Test                                                  30.00
Range of Motion Instrumentation                      30.00
Cryotherapy                                                        10.00
Hydro collator (hot packs)                                 15.00
Traction Mechanical                                           25.00
Electric Muscle Stimulation                               11.00-21.00
Ultrasound                                                           11.00-20.00
Extended Neuro-Emotional Technique            75.00 half hour
Foot orthotics                                                    175.00
Lumbosacral support                                         35.00
Cervical Collar                                                    65.00
Supplements                                                    Accordingly
Laboratory Tests                                              Accordingly
Cooking Class (includes handouts & Cookbook)  50.00
Mind/ Body Mental Focusing Workshop               190.00
Seminars                                                              15 and up








PATIENT ACKNOWLEDGMENT REGARDING
NOTICE OF PRIVACY PRACTICES
BACK COUNTRY CHIROPRACTIC AND WELLNESS CENTER



I have had the opportunity to review the Notice of Privacy Practices at Back Country Chiropractic and Wellness Center and, if  requested, have been supplied with a copy of those practices.  


Patient Name:_______________________________________  Date:________________ Print Name

Patient Signature:______________________________________________


*******************************************************************************************

The HIPAA privacy rule gives individuals the right to request confidential communications or that a communication of private health information be made by alternative means, such as sending correspondence to the individual's office, instead of the individual's home.

I wish to be contacted in the following manner (check all that apply)

[   ]  Home Telephone                         
              [   ]  OK to leave message with detailed information          
              [   ]  Leave message with call-back number only

[   ]  Work Telephone
     [   ] OK to leave message with detailed information
     [   ] Leave message with call-back number only

[   ]  Written Communication
     [   ] OK to mail to my home address
     [   ] OK to mail to my work/office address
     [   ] OK to fax to this number________________________

[   ]  Other___________________________________________________________________________________

_____________________________________    DOB:________________      Date signed:_________________
Patient Signature