Auto Accident Information
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- Moses Merritt
- 5 years ago
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1 Auto Accident Information Today s Date: Date of Accident: Patient Name: Home #: Address: City: Zip: Birthdate: Age: Work #: Address: Cell #: Emergency contact person: How were you referred to our office? Your Auto Insurance Co: Policy #: Claim #: Med Pay Coverage Amount: Date you made the claim: Claims Address: Adjuster Name: Other Party s Name: Address: City: Zip: Birthdate: Home Cell: Their Auto Insurance Co: Policy #: Claim #: Date they made the claim: Claims Address: Adjuster Name:
2 Auto Accident History Patient Name: Date of Accident: Driver of Car: Time: Who owns the car: Where were you seated in the car when the accident occurred? Passengers in your car: Year & Model of your car: Year & Model of the other car: Approximate damage to your car= $ I Don t know yet- I m getting an estimate Visibility at time of the accident: Good Fair Poor Other Road conditions at the time of the accident: Clear Dark Rainy Wet Icy Type of accident: Rear-ended You hit the car in front Head-on collision Broad-side collision (driver side) Broad-side collision (passenger side) Side-swiped Did you see the accident coming? Yes No Did you brace for impact? Yes No Were you wearing your seatbelt and shoulder harness at the time of the accident? Yes No What was the position of those headrests compared to your head before the accident? Top of headrest even with the bottom of your head Top of headrest even with the middle of your neck Top of headrest even with the top of your head My car does not come equipped with headrests Was your head positioned: Straight Forward Turned to the left Turned to the right Did any parts of your head or body hit the inside of the car: Did the safety airbag inflate during the impact? Yes (Front / Side) Did you get any bleeding cuts as a result of the accident?? Yes No No Where? Did you get any bruises as a result of the accident? No Yes- where: Did the police make a report of the accident? Yes No (If yes, please give us a copy) *If no, did you exchange information with the other driver? Yes No Hit & Run
3 As a result of the accident, were you: Shaken and/or shocked that the collision had occurred Rendered almost unconscious Rendered totally unconscious Other: Could you move all parts of your body after the collision? Yes No If not, what parts couldn t you move? Were you able to get out of the car and walk without help? Yes No Describe how you felt after the accident Immediately after the accident: Later that day: The next day: When did you go to the hospital or urgent care center to get checked for your injuries? How did you get to that facility? Ambulance Someone drove me there I drove myself there Name of Hospital: Location: What treatment did you receive? Did they do any special tests? X-Rays MRI CT Scan Blood What other doctors have you seen for these injuries (besides at this office)? Dr. Name: Date: What treatment did you receive? Did they do any special tests? X-Rays MRI CT Scan Blood Any Other Doctors Seen: Please list all medications you are presently taking, what they are for and how often you take them: Your Occupation: Company: Number of full days missed off work/school due to accident: Number of part time days missed off work/school due to accident:
4 Please check any symptoms that you had since the accident: Neck pain/stiffness Headaches Dizziness/Loss of balance Midback pain/stiffness Nausea Ringing in the ears Lower back pain/stiffness Loss of Sleep Blurred vision Numbness in arms/hands Fatigue Shortness of breath Numbness in legs/feet Chest Pain Loss of senses of taste or smell Pain in shoulders Facial Pain Jaw pain / TMJ clicking Muscle Tension/Spasms Depression Anxiety/Irritability Other symptoms: Activities/Sports you cannot perform due to injuries: Neck Pain: Describe how the neck pain feels: Sharp Dull Stiff Swollen Do you have Headaches Numbness or Tingling in: Shoulders Arms Hands How often does the neck pain occur: Constant Comes and Goes Is the neck pain: Improving Getting worse Staying the same On a scale of 1-10, rate the severity of your neck pain: What activities make the neck pain worse? Does the neck pain interfere with your: Work Sleep Exercise Daily activities Mid Back Pain: Describe how the midback pain feels: Sharp Dull Stiff Swollen Do you feel: Radiation of Pain Along the Ribs Sharp Chest Pain Dull Chest Pain Is the pain: Constant Comes&Goes Improving Getting worse Staying same On a scale of 1-10, rate the severity of your midback pain: What activities make the midback pain worse? Does the midback pain interfere with your: Work Sleep Exercise Daily activities
5 Lower Back Pain: Describe how the lower back pain feels: Sharp Dull Stiff Swollen Do you feel: Radiation of pain Numbness/Tingling Is the pain: Constant Comes/Goes Improving Getting worse Staying the same On a scale of 1-10, rate the severity of your lower back pain: What activities make the lower back pain worse? Does the low back pain interfere with your: Work Sleep Exercise Daily activities Other Complaint Area: Describe how the pain feels: Sharp Dull Stiff Swollen Cramping Is the pain: Constant Comes/Goes Improving Getting worse Staying same On a scale of 1-10, rate the severity of your pain in this area: What activities make the pain worse? Does the pain interfere with your: Work Sleep Exercise Daily activities Do you have any other complaints that are related to this accident? If so, please describe: Prior to this accident, have you ever had any of the physical complaints similar to what you have now? Yes No If yes, please describe: Have you had any serious injuries that required medical care? Yes No Describe: Have you had any serious illnesses that required hospitalization? Yes No Describe: Have you had any surgeries/broken bones? Yes No List type of surgery and date:
6 Have you ever been diagnosed with any of these conditions? Please check all that apply: Cancer Type: Diabetes Type: Heart Problem: Treatment: Treatment: Treatment: High Blood Pressure- Last known reading: Stroke Seizures Chest Pain Other Asthma Digestive Problems Allergies Heartburn Gas/Bloating Constipation/Diarrhea Recent Illness Fever Nausea/Vomiting Dizziness Head injuries Concussion Knocked unconscious Spinal Arthritis Where: Disc Herniation- Where/When: Epidural Injection- Where/When: Any other spinal problems: Are you pregnant? Yes No Maybe- my last period was: How would you like to pay for your care? Cash/check Credit Card Insurance Do you have an attorney representing you for this accident? Address: City: Zip: Fax: The above is accurate to the best of my knowledge Signature If the above information applies to your child, I fully authorize any doctor in this office to examine (including x-rays) and provide treatment to my child. Signature I acknowledge that I have received and read a copy of the Notice of Privacy Practices. I give Dr. Rettig, Dr. Martin or Dr. Wintermute my authorization and consent to use and disclose my (or my child s) protected health care information for the purposes of treatment, payment and health care operations, as described in the Notice of Privacy Practices. Signature Print Name Date
PERSONAL INJURY PATIENT HISTORY FORM
PERSONAL INJURY PATIENT HISTORY FORM NAME DATE AUTOMOBILE ACCIDENT INSURANCE INFORMATION Insurance Company Name Claim #: Adjuster s Name Phone # Agent s Name Phone # HISTORY OF OCCURRENCE 1. Date of accident
CHIROPRACTIC CENTER OF ANNAPOLIS 108 Old Solomons Island Rd., Bldg. 2 Annapolis, MD (410) Dr. William J. Boro Dr. Mary X.
CHIROPRACTIC CENTER OF ANNAPOLIS 108 Old Solomons Island Rd., Bldg. 2 Annapolis, MD 21401 (410) 266-5054 Dr. William J. Boro Dr. Mary X. Psaromatis New Patient History Form Patient Name: Date: Please list
PERSONAL HISTORY AUTO ACCIDENT QUESTIONNAIRE. Personal Injury Questionnaire. Name Date. Date of Accident: Time. Location of Accident (Streets)
Personal Injury Questionnaire Patient# HISTORY OF OCCURRENCE Name Date Date of Accident: Time Location of Accident (Streets) As a result of the accident you were: Rendered unconscious In shock Dazed, circumstances
Physical Evidence Chiropractic 7035 Beracasa Way Suite 103 Boca Raton FL, Phone# (561) Fax# (561)
7035 Beracasa Way Suite 103 Boca Raton FL, 33433 Phone# (561)361-4888 Fax# (561)361-4999 Date File # PERSONAL HISTORY Last Name First Name Address City State Zip Date of Birth Age Social Security # Circle
ASSIGNMENT OF BENEFITS
ASSIGNMENT OF BENEFITS PATIENT NAME: First Middle Last PHONE NUMBER: Home: Work: HOME ADDRESS: City ZIP AGE: DOB: SSN: Status EMAIL ADDRESS: PATIENT EMPLOYER: How long? Occupation SPOUSE S EMPLOYER: Spouse
Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code
Gordley Family Chiropractic Clinic Patient Introduction Card First Name MI Last Name Date Address Married Single Mailing Address Phone City State Zip Code Birth Date Social Security Number Employed By
Who may we thank for referring you?
NEW PRACTICE MEMBER APPLICATION Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
New Practice Member Application
New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
Patient Introduction Card
Patient Introduction Card No. Date: Name (Mr. Mrs. Miss Ms.): Home Phone: ( ) Email Address (ex: name@email.com): Address: City: State: Zip: Married Single Other: Age: Date of Birth: / / Occupation: Employer:
Matthews Family Chiropractic
Dr. John J. Hanna, Director Matthews Family Chiropractic Windsor Square 9808 Northeast Parkway Matthews, NC 28105 (704) 845-0699 CASE HISTORY PLEASE PRINT Name: Home Phone: Address: City: Zip: Page 1 Age:
Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
Somerset Hills Physical Therapy, PC 180 Mount Airy Road, Suite 103 Basking Ridge, NJ 07920 Phone (908) 766-1407 Fax (908) 953-8454 wwwsomersethillsptcom Patient Information: Name Sex M F Date of Birth
AUTO ACCIDENT QUESTIONNAIRE
AUTO ACCIDENT QUESTIONNAIRE Name Date of Birth Age Address City State Zip NATURE OF ACCIDENT: 1. Date of Accident Time of Day (AM / PM) 2. Were you the ( ) Driver or ( ) Passenger? 3. If a passenger were
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
Patient Re-Examination Form
Harrisburg Family Chiropractic 220 S. Cliff Ave. Ste 106 Harrisburg SD 57032 (605) 767-7463 Name: Date: / / Patient Re-Examination Form Please fill out the information that has changed since your last
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Personal Information: Name: Home phone #: Address: Alt. phone #: City/State/Zip: Email address: Date of birth: Age: Social Security #: Insurance Information: (Vehicle You
Home Phone # Cell Phone # Address. Occupation Employer. Work Address Work Phone # Person to Contact in an emergency Phone #
MOTOR VEHICLE ACCIDENT HISTORY (please print) Patient Information Dr./Mr./Mrs./Ms./Miss (circle one) Marital Status (circle one) M S W D Last Name First Name Middle Name Address City Province Postal Code
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Name Phone ( ) Age Birth Date Sex S.S.N. Employer Address Did you report this to YOUR Car Insurance? Yes No (Circle One) Your Car Insurance Co. is Claim # Claims Adjuster
LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL
Whom may we thank for referring you to this office Today s Date: PATIENT DEMOGRAPHICS? HRN: Name: Birth Date: Age: Male Female Address: City: State: Zip: E mail Address: Home Phone: Mobile Phone: Marital
Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)
Name_ Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon) For reminders do you prefer Phone Calls, Text Messages or Emails? CALL ME / TEXT ME / EMAIL ME Email Address
Current Health Information
Name: : / / Current Health Information List your health concerns below: Health Concerns: (List according to severity) Rate of Severity 1 = Mild 10 = Unbear able When did the Symptom s Start? Are the Symptoms
Last Name First Name M.I Nickname Address City State Zip_. Date of Birth Age Gender: M F Marital Status: S M W D INJURY INFORMATION
PATIENT REGISTRATION Date: Last Name First Name M.I Nickname Address City State Zip_ Mobile Phone Home Phone Work Phone E-Mail SSN Date of Birth Age Gender: M F Marital Status: S M W D Employer Name Occupation_
Brisbin Family Chiropractic
Information reviewed with patient: Dr. Initials Today s Date Brisbin Family Chiropractic Name: Sex: Male Female Address: City: Postal Code: Home Ph# Work# Ext# Cell# Preferred number (circle one) Home
Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
Personal Injury Questionnaire. Name: Address: City: State: Zip: Cell Phone: Home phone: Work Phone: Social Security Number:
Personal Injury Questionnaire Name: Address: City: State: Zip: Cell Phone: Home phone: Work Phone: Social Security Number: Email: Date of birth Sex: Male Female Marital States S M D W Date of Accident:
NEW PATIENT INFORMATION
OrthoNeuro For every motion in life. NEW PATIENT INFORMATION NAME: AGE: DATE: REFERRING DOCTOR/THERAPIST: SELF REFERRAL (if so, circle) Are you: Male Female Right handed Left handed Ambidextrous CHIEF
MOORE CHIROPRACTIC CENTER 707 Sunset Street Denton, TX (940)
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New Practice Member Paperwork
Cornerstone Family Chiropractic Health Information Form 928.237.9477 www.cfc4familyhealth.com 2225 E State Route 69 Suite A Prescott, AZ 86301 New Practice Member Paperwork This form is for adults only.
Welcome to our office!
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Revelation Chiropractic Health Profile
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SMITH CHIROPRACTIC HEALTH PROFILE Today s Date:
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COMPREHENSIVE HEALTH & WELLNESS PROFILE
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PATIENT INJURY/MEDICAL HISTORY FORM
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Puritz Chiropractic Center Patient Health Questionnaire
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634 N. STATE STREET, WESTERVILLE OH, (614) 901-WELL
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Date. Patient General Information
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Page1 PERSONAL INFORMATION Last Name First Nickname Middlle Initial Prefix Generation Sex DOB SSN Marital Status Height Weight Address City State Zip Phone (Home) (Work) (Cell) Email Occupation Employer
Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:
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CHIROPRACTIC INTAKE FORM
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Pain Management Questionnaire
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Date: Can we leave messages on voice mail at home/work/cell? Yes No. Sex: Male Female SS#: If yes, what type? Auto Work Other.
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
Name Date / / Age Male/ Female Address City State Zip
T 1 2 3 : Name _ Date / / Age Male/ Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Address Date of Birth / / Occupation Employer Single / Married / Divorced / Widowed Spouse s
SPARROW FAMILY CHIROPRACTIC
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APPLICATION FOR CARE
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History of Present Condition
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The failure to bring this information with you may result in the rescheduling of your appointment.
Alan Koester, MD Steven Novotny, MD John Jasko, MD Viorel Raducan, MD Brock Niceler, MD Thomas Reinsel, MD Chad Lavender, MD Thank you for choosing Marshall Orthopaedics! We will make every effort to ensure
Today s Date: What are your health goals? Symptom relief and preventing its return 100% optimum health and wellbeing on every level available to me
Today s : MHSC REGISTRATION # (6 DIGIT) (9 DIGIT) First Name: Last Name: I am a Male/Female (circle) Birthday (d/m/y): / / Current Age: Street Address: City: Province: Postal Code: Home #: Work #: Cell
PATIENT REGISTRATION FORM
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HEALTH INFORMATION FORM
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APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS HRN: Name: Birth Date: - - Age: o Male o Female Address: City: State:
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire Name: MR#:_ Date: Date of Injury: Referred By: Age: Date of Birth: Handed: R L Ambidextrous Male Female **** Mark
Adult New Patient Intake. Your Health Summary
Adult New Patient Intake Name Age Birth Date / / Soc. Sec. # - - Home Phone Cell Phone Address: City: State: Zip: Occupation: Email Marital Status: M W D S Spouse s Name: Children # and Ages: Whom may
Personal and Family Health History
Personal and Family Health History Date Name Social Security Address Occupation City State Zip Employer Phone: (H): (W): Marital Status: S M D W E-mail Spouse s Name Date of Birth Age Spouse s Occupation
Accident or Injury Form 1 TODAY'S DATE: PATIENT INFORMATION Last Name: First Name: MI: Birth Date:
Accident or Injury Form 1 NECK, MIDDLE BACK & UPPER EXTREMITY QUESTIONNAIRE YES NO NECK REGION Does neck and head movement cause your neck pain to intensify? Do you get dizzy when you look up or twist
Orthodontic Questionnaire. Please tell us why you have presented for evaluation and possible treatment. Dental History
Orthodontic Consultation file:///c:/programdata/nierman/dentalwriternet/reports/out.html Version: ORTHOQ Orthodontic Questionnaire OFFICE USE Patient ID: NAME: -' Crowding ' Overbite CURRENT DATE: / /
RED-ROSE CHIROPRACTIC CLINIC, P.S NE 85 TH STREET KIRKLAND, WA (425) fax (425)
PATIENT INFORMATION DATE: BP: P: Patient Name: (First) (Last) (M.I.) Address: City, State: Zip Code: Home #: ( ) Cell #: ( ) Work #: ( ) Date of Birth: Age: Sex: M / F Email: Automatic Appointment Reminder
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac. Personal History: Name: Address: City: Province: Postal Code: Birth date: day /month /year Age: Sex: M F Home Phone: Business Phone: Cell Phone: E-mail: Health
New Member Contact Information
New Member Contact Information Date: Social Security #: - - File Number: First Name: Middle Initial: Last Name: Age: Birth Date: / / Gender: M F Marital Status: S M D W Home Address: Home Phone: - - City,
Chiropractic Case History/Patient Information
1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Cell Phone: Age: Birth Date: Race: Marital Status: [M] [S ][W] [D] Occupation:
Chiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
Cascadia Chiropractic Centre
Name: Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: Date of Birth: Your age: Care Card #: Address: City/Prov: Postal Code: Phone: Cell: Work Phone: E-mail Address: Marital
APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
Chiropractic Case History/Patient Information. Social Security # Home Phone: Address: City: State: Zip: address: Fax # Cell Phone:
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Tassin Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital: