Hargrave Chiropractic, LLC Motor Vehicle Collision Questionnaire Christopher S. Hargrave, DC. Patient Name:

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1 Address: City: State: Zip Cde H. Phne: W. Phne: Cell Phne: Address: Sex M F Marital Status M S D Date f Birth: Age: Scial Security #: Occupatin: Emplyer: Jb Details/Activities: Have yu ever received Chirpractic Care? Y/N If yes, when and fr what? Name f mst recent Chirpractr: Please cmplete all the fllwing questins regarding yur accident. These details are very imprtant and will assist the dctr in prperly diagnsing and dcumenting yur injuries. 1. Previus interventins, treatments, medicatins, surgery, r care yu ve sught fr yur cmplaint(s): 2. Since the Mtr Vehicle Cllisin, have yu experienced any f the fllwing: A. Lss f Range f Mtin: yes/n a. What bdy parts: B. Visual Disturbance : yes/n blurring l/r flaters l/r visin lss l/r hypersensitivity l/r % f time: % f time: % f time: % f time: C. Dizziness: yes/n % f time: D. Anxiety: yes/n % f time: E. Depressin: yes/n % f time: F. Difficulty Sleeping: yes/n % f time: 3. Past Health Histry: A. Please indicate if yu have a histry f any f the fllwing: Anticagulant use Heart prblems/high bld pressure/chest pain Bleeding prblems Lung prblems/shrtness f breath Cancer Diabetes Psychiatric disrders Biplar disrder Majr depressin Schizphrenia Strke/TIA s Other Nne f the abve B. Previus Injury r Trauma: Have yu ever brken any bnes? Which? C. Allergies: D. Medicatins: Medicatin Reasn fr taking E. Surgeries: Date Type f Surgery 404 Westgate Rad #B, Lafayette, LA (P) (F)

2 F. Females/ Pregnancies and utcmes: Pregnancies/Date f Delivery Outcme 4. Family Health Histry: D yu have a family histry f? (Please indicate all that apply) Cancer Strkes/TIA s Headaches Cardiac disease Neurlgical diseases Adpted/Unknwn Cardiac disease belw age 40 Psychiatric disease Diabetes Other Nne f the abve Deaths in immediate family: Cause f parents r siblings death Age at death 5. Scial and Occupatinal Histry: A. Jb descriptin: B. Wrk schedule: C. Recreatinal activities: D. Lifestyle (hbbies, level f exercise, alchl, tbacc and drug use, diet): Review f Systems Have yu had any f the fllwing pulmnary (lung-related) issues? Asthma/difficulty breathing COPD Emphysema Other Nne f the abve Have yu had any f the fllwing cardivascular (heart-related) issues r prcedures? Heart surgeries Cngestive heart failure Murmurs r valvular disease Heart attacks/mis Heart disease/prblems Hypertensin Pacemaker Angina/chest pain Irregular heartbeat Other Nne f the abve Have yu had any f the fllwing neurlgical (nerve-related) issues? Visual changes/lss f visin One-sided weakness f face r bdy Histry f seizures One-sided decreased feeling in the face r bdy Headaches Memry lss Tremrs Vertig Lss f sense f smell Strkes/TIAs Other Nne f the abve Have yu had any f the fllwing endcrine (glandular/hrmnal) related issues r prcedures? Thyrid disease Hrmne replacement therapy Injectable sterid replacements Diabetes Other Nne f the abve Have yu had any f the fllwing renal (kidney-related) issues r prcedures? Renal calculi/stnes Hematuria (bld in the urine) Incntinence (can t cntrl) Bladder Infectins Difficulty urinating Kidney disease Dialysis Other Nne f the abve Have yu had any f the fllwing gastrenterlgical (stmach-related) issues? Nausea Difficulty swallwing Ulcerative disease Frequent abdminal pain Hiatal hernia Cnstipatin Pancreatic disease Irritable bwel/clitis Hepatitis r liver disease Bldy r black tarry stls Vmiting bld Bwel incntinence Gastresphageal reflux/heartburn Other Nne f the abve Have yu had any f the fllwing hematlgical (bld-related) issues? 404 Westgate Rad #B, Lafayette, LA (P) (F)

3 Anemia Regular anti-inflammatry use (Mtrin/Ibuprfen/Naprxen/Naprsyn/Aleve) HIV psitive Abnrmal bleeding/bruising Sickle-cell anemia Enlarged lymph ndes Hemphilia Hypercagulatin r deep venus thrmbsis/histry f bld clts Anticagulant therapy Regular aspirin use Other Nne f the abve Have yu had any f the fllwing dermatlgical (skin-related) issues? Significant burns Significant rashes Skin grafts Psriatic disrders Other Nne f the abve Have yu had any f the fllwing musculskeletal (bne/muscle-related) issues? Rheumatid arthritis Gut Ostearthritis Brken bnes Spinal fracture Spinal surgery Jint surgery Arthritis (unknwn type) Sclisis Metal implants Other Nne f the abve Have yu had any f the fllwing psychlgical issues? Psychiatric diagnsis Depressin Suicidal ideatins Biplar disrder Hmicidal ideatins Schizphrenia Psychiatric hspitalizatins Other Nne f the abve Is there anything else in yur past medical histry that yu feel is imprtant t yur care here? I have read the abve infrmatin and certify it t be true and crrect t the best f my knwledge, and hereby authrize this ffice f Chirpractic t prvide me with chirpractic care, in accrdance with this state's statutes. If my insurance will be billed, I authrize payment f medical benefits t Christpher S. Hargrave, DC/Hargrave Chirpractic, LLC fr services perfrmed. Patient r Guardian (Printed): Patient r Guardian (Signature): Cntinue t the next page please, Thanks! 404 Westgate Rad #B, Lafayette, LA (P) (F)

4 HIPAA NOTICE OF PRIVACY PRACTICES THIS 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. This Ntice f Privacy describes hw we may use and disclse yur prtected health infrmatin (PHI) t carry ur treatment, payment r health care peratins (TPO) fr ther purpses that are permitted r required by law. Prtected Health Infrmatin is infrmatin abut yu, including demgraphic infrmatin that may identify yu and that related t yur past, present, r future physical r mental health r cnditin and related care services. Use and Disclsures f Prtected Health Infrmatin: Yur prtected health infrmatin may be used and disclsed by yur physician, ur staff and thers utside f ur ffice that are invlved in yur care and treatment fr the purpse f prviding health care services t yu, pay yur health care bills, t supprt the peratins f the physician s practice, and any ther use required by law. Treatment: We will use and disclse yur prtected health infrmatin t prvide, crdinate, r manage yur health care and any related services. This includes the crdinatin r management f yur health care with a third party. Fr example, we wuld disclse yur prtected health infrmatin, as necessary, t a hme health agency that prvides care t yu. Fr example, yur health care infrmatin may be prvided t a physician t whm yu have been referred t ensure that the physician has the necessary infrmatin t diagnse r treat yu. Payment: Yur prtected health infrmatin will be used, as needed, t btain payment fr yur health care services. Fr example, btaining apprval fr a hspital stay may require that yur relevant prtected health infrmatin be disclsed t the health plan t btain apprval fr the hspital admissin. Healthcare Operatins: We may disclse, as needed, yur prtected health infrmatin in rder t supprt the business activities f yur physician s practice. These activities include, but are nt limited t, quality assessment activities, emplyee review activities, training f medical students, licensing, marketing, and fund raising activities, and cnductin r arranging fr ther business activities. Fr example, we may disclse yur prtected health infrmatin t medical schl students that see patients at ur ffice. In additin, we may use a sign-in sheet at the registratin desk where yu will be asked t sign yur name and indicate yur physician. We may als call yu by name in the waiting rm when yur physician is ready t see yu. We may use r disclse yur prtected health infrmatin, as necessary, t cntact yu t remind yu f yur appintment. We may use r disclse yur prtected health infrmatin in the fllwing situatins withut yur authrizatin. These situatins included as required by law, public health issues, cmmunicable diseases, health versight, abuse r neglect, fd and drug administratin requirements, legal prceedings, law enfrcement, crners, funeral directrs, and rgan dnatin. Required uses and disclsures under the law, we must make disclsures t yu when required by the Secretary f the Department f Health and Human Services t investigate r determine ur cmpliance with the requirements f Sectin OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES WILL BE MADE ONLY WITH YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT UNLESS REQUIRED BY LAW. Yu may revke this authrizatin, at any time, in writing, except t the extent that yur physician r the physician s practice has taken an actin in reliance n the use r disclsure indicated in the authrizatin. Patient r Guardian (Printed): Patient r Guardian (Signature): 404 Westgate Rad #B, Lafayette, LA (P) (F)

5 Infrmed Cnsent t Care Yu are the decisin maker fr yur health care. Part f ur rle is t prvide yu with infrmatin t assist yu in making infrmed chices. This prcess is ften referred t as infrmed cnsent and invlves yur understanding and agreement regarding the care we recmmend, the benefits and risks assciated with the care, alternatives, and the ptential effect n yur health if yu chse nt t receive the care. We may cnduct sme diagnstic r examinatin prcedures if indicated. Any examinatins r tests cnducted will be carefully perfrmed but may be uncmfrtable. Chirpractic care centrally invlves what is knwn as a chirpractic adjustment. There may be additinal supprtive prcedures r recmmendatins as well. When prviding an adjustment, we use ur hands r an instrument t repsitin anatmical structures, such as vertebrae. Ptential benefits f an adjustment include restring nrmal jint mtin, reducing swelling and inflammatin in a jint, reducing pain in the jint, and imprving neurlgical functining and verall well-being. It is imprtant that yu understand, as with all health care appraches, results are nt guaranteed, and there is n prmise t cure. As with all types f health care interventins, there are sme risks t care, including, but nt limited t: muscle spasms, aggravating and/r temprary increase in symptms, lack f imprvement f symptms, burns and/r scarring frm electrical stimulatin and frm ht r cld therapies, including but nt limited t ht packs and ice, fractures (brken bnes), disc injuries, strkes, dislcatins, strains, and sprains. With respect t strkes, there is a rare but serius cnditin knwn as an arterial dissectin that typically is caused by a tear in the inner layer f the artery that may cause the develpment f a thrmbus (clt) with the ptential t lead t a strke. The best available scientific evidence supprts the understanding that chirpractic adjustment des nt cause a dissectin in a nrmal, healthy artery. Disease prcesses, genetic disrders, medicatins, and vessel abnrmalities may cause an artery t be mre susceptible t dissectin. Strkes caused by arterial dissectins have been assciated with ver 72 everyday activities such as sneezing, driving, and playing tennis. Arterial dissectins ccur in 3-4 f every 100,000 peple whether they are receiving health care r nt. Patients wh experience this cnditin ften, but nt always, present t their medical dctr r chirpractr with neck pain and headache. Unfrtunately, a percentage f these patients will experience a strke. The reprted assciatin between chirpractic visits and strke is exceedingly rare and is estimated t be related in ne in ne millin t ne in tw millin cervical adjustments. Fr cmparisn, the incidence f hspital admissin attributed t aspirin use frm majr GI events f the entire (upper and lwer) GI tract was 1219 events/ per ne millin persns/year and risk f death has been estimated as 104 per ne millin users. It is als imprtant that yu understand there are treatment ptins available fr yur cnditin ther than chirpractic prcedures. Likely, yu have tried many f these appraches already. These ptins may include, but are nt limited t: selfadministered care, ver-the-cunter pain relievers, physical measures and rest, medical care with prescriptin drugs, physical therapy, bracing, injectins, and surgery. Lastly, yu have the right t a secnd pinin and t secure ther pinins abut yur circumstances and health care as yu see fit. I have read, r have had read t me, the abve cnsent. I appreciate that it is nt pssible t cnsider every pssible cmplicatin t care. I have als had an pprtunity t ask questins abut its cntent, and by signing belw, I agree with the current r future recmmendatin t receive chirpractic care as is deemed apprpriate fr my circumstance. I intend this cnsent t cver the entire curse f care frm all prviders in this ffice fr my present cnditin and fr any future cnditin(s) fr which I seek chirpractic care frm this ffice. Patient r Guardian (Printed): Patient r Guardian (Signature): 404 Westgate Rad #B, Lafayette, LA (P) (F)

6 NEW PATIENT HISTORY FORM Please start at the tp f yur bdy and wrk yur way dwn, i.e. Headache, Neck Pain, etc. Symptm 1 On a scale frm 1-10, with 10 being the wrst, please circle the number that best describes the symptm mst f the time: What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: When did the symptm begin? Was this symptm a result f a mtr vehicle cllisin? Yes/N (circle ne) Did yu have this symptm befre this mtr vehicle cllisin? Yes/N If s, what was the intensity (1-10 w/10 the wrst) and frequency? What makes the symptm wrse? (circle all that apply): Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, twisting left at waist, twisting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please describe): What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other (please describe): Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging, Other (please describe): Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day Symptm 2 On a scale frm 1-10, with 10 being the wrst, please circle the number that best describes the symptm mst f the time: What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: When did the symptm begin? Was this symptm a result f a mtr vehicle cllisin? Yes/N (circle ne) Did yu have this symptm befre this mtr vehicle cllisin? Yes/N If s, what was the intensity (1-10 w/10 the wrst) and frequency? What makes the symptm wrse? (circle all that apply): Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, twisting left at waist, twisting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please describe): What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other (please describe): Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging, Other (please describe): Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day 404 Westgate Rad #B, Lafayette, LA (P) (F)

7 Symptm 3 On a scale frm 1-10, with 10 being the wrst, please circle the number that best describes the symptm mst f the time: What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: When did the symptm begin? Was this symptm a result f a mtr vehicle cllisin? Yes/N (circle ne) Did yu have this symptm befre this mtr vehicle cllisin? Yes/N If s, what was the intensity (1-10 w/10 the wrst) and frequency? What makes the symptm wrse? (circle all that apply): Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, twisting left at waist, twisting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please describe): What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other (please describe): Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging, Other (please describe): Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day Symptm 4 On a scale frm 1-10, with 10 being the wrst, please circle the number that best describes the symptm mst f the time: What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: When did the symptm begin? Was this symptm a result f a mtr vehicle cllisin? Yes/N (circle ne) Did yu have this symptm befre this mtr vehicle cllisin? Yes/N If s, what was the intensity (1-10 w/10 the wrst) and frequency? What makes the symptm wrse? (circle all that apply): Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, twisting left at waist, twisting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please describe): What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other (please describe): Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging, Other (please describe): Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day 404 Westgate Rad #B, Lafayette, LA (P) (F)

8 Please cmplete ALL the fllwing questins regarding yur accident. These details are very imprtant and will assist the dctr in prperly diagnsing and dcumenting yur injuries. Date f accident: Type f vehicle(s) invlved: Lcatin f accident (intersectin/street): City: State: Time f accident: Other Details: Explain the mtr vehicle cllisin in yur wn wrds: What area(s) ARE OR WERE painful since the accident? (Circle ALL areas) Neck Upper back Mid back Lwer back Shulder (R/L) Elbw (R/L) Wrist (R/L) Hand (R/L) Hip (R/L) Knee (R/L) Ankle (R/L) Ft (R/L) Headaches Other: New nset f headaches? Yes N (If Yes, Wrsening Imprving Same) Lcatin f headache: Frnt Back Side f head ( Right Left Bth) Behind eye Other: Hw wuld yu describe yur headache? Thrbbing Achy Pressure Sharp Other: Other symptms: Dizziness Light-headedness Nausea Visual prblems Memry lss Vmiting Urinary prblems Cnstipatin Diarrhea Jaw pain Paralysis Sleeplessness Restlessness Frgetful/fggy Numbness Tingling Disrientatin Ringing /buzzing in ears Decreased cncentratin Numb/tingling Weakness/heaviness in legs/arms Difficulty swallwing Difficulty breathing Sre thrat Scapular pain After the accident, when did yur symptms begin? Immediately < 6 hrs 1/2 day later 24 hrs 48 hrs Seat belt n? Yes N Did airbags deply? Yes N Which nes? Frnt Side Hw has yur pain prgressed since the accident? Wrse Same Imprved Where were yu in the vehicle? Driver Frnt right passenger Back left (behind driver) Back right Other: Hw was yur head psitined at the time f the cllisin? Hw was yur bdy psitined at the time f the cllisin? If yu were the driver, where was yur right ft when the accident happened? On the brake On the gas pedal Resting n the flr Bracing What part f the car in which yu were sitting was hit? (Check ALL that apply) Frnt Rear Left side Right side Left crner Right crner Other During the accident, hw did yur bdy mve? (Check ALL that apply) Vilently jlted in seat Thrwn frward Thrwn backward Thrwn left Thrwn right Were yu aware that the accident was abut t happen? Yes N Were yu braced fr the impact? Yes N Did any part f yur bdy (INCLUDING YOUR HEAD) strike anything in/n the car? (Driver s dr, windshield, gearshift, etc.) A. Bdy part struck B. Bdy part struck C. Bdy part struck Did yu lse cnsciusness? Yes N If Yes, fr hw lng? D yu/did yu have amnesia? Yes N Was yur car stpped at the time f the accident? Yes N If N, what was yur speed? The car was: Slwing dwn Gaining speed Driving at a steady rate Did the cllisin push/mve yur car? Yes N If Yes, in which directin? Frward Backward Sideways Diagnally 404 Westgate Rad #B, Lafayette, LA (P) (F)

9 Hw far were yu pushed (apprx.)? If pushed, did yur car strike anther car/bject? Yes N If Yes, what? Were yu seen at a hspital? Yes N If Yes, hw many hurs after the accident? Hspital name Hw did yu get t the hspital? Were X-rays taken? Yes N If Yes, f what? Medicatins prescribed at the hspital: Muscle relaxant Anti-inflammatry Painkiller Other medicatin(s): Time ff frm wrk given? Yes N If Yes, frm t Previus accidents r significant injuries t areas injured in this cllisin Type f accident: Area (s) injured: Recver cmpletely: Type f accident: Area (s) injured: Recver cmpletely: Were any f the areas injured in the present accident symptmatic befre the accident? Yes N If Yes, explain: Drawing f cllisin: I agree that all the abve infrmatin is crrect and true t the best f my knwledge. Patient r Guardian (Printed): Patient r Guardian (Signature): 404 Westgate Rad #B, Lafayette, LA (P) (F)

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