PERSONAL INJURY QUESTIONNAIRE
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- Marianna McKenzie
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1 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 for this Claim Phone # Name on Policy (if other than yourself) ATTORNEY INFORMATION Name Phone ( ) Were there Witnesses? ( ) Yes ( ) No Name(s) NATURE OF ACCIDENT 1. Date of accident Time of Day 2. Were you: ( ) Driver ( ) Passenger ( ) Front Seat ( ) Back Seat 3. Number of people in your vehicle 4. Were you wearing your seat belt? ( ) Yes ( ) No 5. What direction were you headed? ( ) North ( ) South ( ) East ( ) West 6. What direction was other vehicle headed? ( ) North ( ) South ( ) Left Side ( ) Right Side 7. Name of street or Highway: 8. From which direction were you struck? ( ) Behind ( ) Front ( ) Left Side ( ) Right Side 9. Approximate speed of your car was mph. Approximate speed of the other car was mph. 10. Were you knocked unconscious? ( ) Yes ( ) No 11. Were police notified? ( ) Yes ( ) No 12. In your own words, please describe the accident. 13. Did you have any physical complaints BEFORE THE ACCIDENT? ( ) Yes ( ) No If yes, please describe in detail. 14. Please describe how you felt: a. DURING the accident b. IMMEDIATELY AFTER the accident c. LATER THAT DAY d. THE NEXT DAY
2 15. What are your PRESENT complaints and symptoms? 16. Do you have any congenital (from birth) factors which relate to this problem? ( ) Yes ( ) No If yes, please describe: 17. Do you have any illnesses that relate to this case? ( ) Yes ( ) No If yes, please describe: 18. Were you taken to the hospital after the accident? ( ) Yes ( ) No Where? 19. Have you been treated by another doctor since this accident? ( ) Yes ( ) No Who? 20. Since the injury occurred, are your symptoms: ( ) Improving ( ) Getting Worse ( ) Staying the Same 21. CHECK SYMPTOMS YOU HAVE NOTICED SINCE THE ACCIDENT: [ ] Headache [ ] Irritability [ ] Numbness in Toes [ ] Face Flushed [ ] Feet Cold [ ] Neck Pain [ ] Chest Pain [ ] Shortness of Breath [ ] Buzzing in Ears [ ] Hands Cold [ ] Neck Stiff [ ] Dizziness [ ] Fatigue [ ] Loss of Balance [ ] Stomach Upset [ ] Sleep Problems [ ] Head Seems Heavy [ ] Depression [ ] Fainting [ ] Constipation [ ] Back Problems [ ] Pins & Needles in Arms [ ] Light Bothers Eyes [ ] Loss of Smell [ ] Cold Sweats [ ] Nervousness [ ] Pins & Needles in Legs [ ] Loss of Memory [ ] Loss of Taste [ ] Fever [ ] Tension [ ] Numbness in Fingers [ ] Ears Ring [ ] Diarrhea Symptoms other than above: 22. Have you lost time as a result of this accident? ( ) Yes ( ) No If yes, please complete this question: a. Last Day Worked: b. Type of Employment: c. Present Salary: d. Are you being compensated for time lost from work? ( ) Yes ( ) No If yes, please state type of compensation you are receiving (e.g. Worker s Comp., State Disability): 23. Do you notice any activity restrictions as a result of this injury? ( ) Yes ( ) No If yes, please describe in detail: 24. Have you ever been involved in an accident before? ( ) Yes ( ) No If yes, please describe, including date(s) and type(s) of accidents, as well as injury(ies) received: _ 25. Other pertinent information: _ Date: Signature:
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4 Athens Chiropractic Clinic Patient Present Complaints Name Date Telephone Social Security# Driver Lic.# Age Birthdate I I Sex M / F Status M S W D No. Children Occupation Employer Years Employed Address City State Zip Work Phone Ext. Referred By: Spouse's Name Occupation Employer Soc. Sec.# Please describe your problem and how it began. Date problem began: / / How bad is your pain? (Circle a number) No Pain Unbearable Pain How often are your symptoms present? o Constantly o Frequently o Occasionally o Intermittently Describe your current pain/symptoms: o Sharp/Stabbing o Throbbing o Aches o Dull o Soreness o Weakness o Numbness o Shooting o Gripping o Burning o Tingling o Other Since it began, is your problem: o Improving o Getting Worse o No Change What makes the problem better? o Nothing o Lying Down o Walking o Standing o Sitting o Movement o Exercise o Inactivity/rest o Other What makes the problem worse? o Nothing o Lying Down o Walking o Standing o Sitting o Movement o Exercise o inactivity/rest o Other Can you perform your daily home activities? o Yes o Yes, only with help o Not at all Do you exercise? o Yes, almost daily o Yes, occasionally o Not at all Describe your job requirements: o Mainly sitting o Light Labor o Heavy Labor Can you perform your daily work activities? o Yes, all activities o Only some o Not at all Describe your stress level: o None to mild o Moderate o High What treatment have you had for this condition in the past? (surgery, medications, injections, therapy, chiropractic) Have you had X-rays, MR or other tests for this condition? What tests and When? MARK AN X ON THE PICTURE WHERE YOU HAVE PAIN OR OTHER SYMPTOMS. INCLUDE SYMPTOMS OF PAIN, NUMBNESS OR TINGLING Patient Signature: Date:
5 Athens Chiropractic Clinic Patient Health Questionnaire Patient Name Patient ID# If you have ever had a listed symptom in the past, please check that symptom in the Past Column. If you are presently troubled by a particular symptom, check that symptom in the Present column. KNOWLEDGE OF THESE CONDITIONS MAY INFLUENCE THE TYPE OF TREATMENT/THERAPY YOU RECEIVE. Past Present Condition Past Present Condition Neck Pain Depression Shoulder Pain (R L ) Aortic Aneurysm Pain in Upper Arm or Elbow (R L ) High Blood Pressure Hand Pain (R L Angina Wrist Pain (R L Heart Attack (date) Upper Back Pain Stroke (date) Low Back Pain Asthma Pain in Upper Leg or Hip (R L ) Cancer, Explain Pain in Lower Leg or Knee (R L ) Tumor, Explain Pain in Ankle or Foot (R L ) Prostate Problems Jaw Pain Blood Disorder Swelling, Stiffness of Joint(s) Emphysema (chronic lung disorders) Fainting Arthritis Visual Disturbances Rheumatoid Arthritis Convulsions Diabetes Dizziness Epilepsy Headache Ulcer Muscular Incoordination Liver / Gallbladder problems Tinnitus (Ear Noises) Kidney Stones Rapid Heart Beat Hepatitis Chest Pains Bladder Infection Loss of Appetite Kidney Disorders (by condition) Anorexia Colitis Abnormal Weight Irritable Colon Gain Loss HIV/AIDS Excessive Thirst Other Chronic Cough If a family member has had any of the following, Chronic Sinusitis please mark the appropriate box: General Fatigue Cancer Epilepsy Irregular Menstral Flow Rheumatoid Chronic Back Problems Profuse Menstral Flow Diabetes Chronic Headaches Breast Soreness Lumps Heart Problems Lupus Endometriosis Lung Problems Other PMS High Blood Pressure Loss of Bladder Control Painful Urination Do you have a permanent disability rating? Yes No Frequent Urination Location Abdominal Pain Date rating received Constipation/irregular bowel habits Rating Percentage Difficulty in Swallowing Heartburn/Indigestion Present Weight pounds Dermatitis/Eczema/Rash Height feet inches Please check any of the following that apply to you. Pregnancy, # births Tobacco Birth Control Pills, type Alcohol Medications (list if not listed elsewhere) Drug or Alcohol Dependence Coffee/Tea/Caffinated Soft drinks: Hospitalizations/Surgical Procedures cups/cans per day: I certify that the above information is complete and accurate to the best of my knowledge. I agree to notify this doctor immediately whenever I have changes in my health condition or health plan coverages in the future. Patient's Signature: Date:
PERSONAL INJURY QUESTIONNAIRE
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SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
Employed? Yes No Employer Name. Occupation. Problem Onset Frequency Severity E.g. Headaches June times per week Mild / Moderate / Severe
PLEASE NOTE: This file must be saved to your desktop before and after completing! PATIENT INFORMATION Date First Name SSN Sex Marital Status Middle Name Birth Date Last Name Height Spouse Name Address
Notto Chiropractic Health Center Patient Information
Notto Chiropractic Health Center Patient Information Acct #: Name: Preferred Name: Address: City: State: Zip: Home Phone: ( ) - _. Work Phone: ( ) -. Who Referred You? In Case of Emergency: Phone Number:
Patient History Questionnaire
Patient History Questionnaire Date: Referred By: Name: DOB: Age: SSN: Home Telephone: Cell Phone: E-mail: Blood Pressure: Weight: Height: (Circle) R or L Handed (Check) Medication List Attached Emergency
Family First Chiropractic
Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of Birth / / Sex: Male Female
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.
SPINE AND ORTHOPEDIC PAIN CENTER, P.C. WINIFRED D. BRAGG, M.D.
SPINE AND ORTHOPEDIC PAIN CENTER, P.C. WINIFRED D. BRAGG, M.D. PATIENT INFORMATION Patient Name (Last, First, Middle Initial) Home Address Gender (M/F) Phone (Home) City State Zip code Phone (Work) Marital
COOK CHIROPRACTIC CLINIC 1715 S MAIN ST KANNAPOLIS NC FX:
COOK CHIROPRACTIC CLINIC 1715 S MAIN ST KANNAPOLIS NC 28081 704-938-7111 FX:704-932-4066 Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address Line
Patient Information. Refurredby. Emergency Contact. Have you ever had chiropractic care before? For what problem? No ----
Patient Information Name ----------------------------------------------------------- Address --------------------------------------------------------- City State Zip Home Phone -------------------------
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
Name First Middle Initial Last Today s Date Address Street City State Zip Date of Birth Age Social Security # Sex: Male Female mm/dd/year Primary Phone # Cell # Email Emergency Contact Name Number Marital
Tell Us About You. Tell Us Why You re Here
Case Number Today s Date CA DC Tell Us About You Title: First: MI: Last: Nickname: Birth date: Age: Sex: Male Female Current address: City: State: Zip: SS #: - - Primary Tel: - - H / W / C Alt. Tel: -
Patient Intake Dr. Kimberly Bensen For TMJ Symptoms
PATIENT NAME: DATE: EMAIL ADDRESS: @ ADDRESS: CITY: STATE: ZIP: Primary PHONE: SOCIAL SECURITY #: AGE: DOB / / SEX: M F HEIGHT: WEIGHT: On the diagram below, place a number (none 0 to 10 worse), that corresponds
634 N. STATE STREET, WESTERVILLE OH, (614) 901-WELL
eas 634 N. STATE STREET, WESTERVILLE OH, 43082 (614) 901-WELL www.abilitychiro.com Name: Age: Date: Address: City: State: Zip Code: Alternate Address: City: State: Zip Code: Cell Phone: ( ) Cell Phone
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
NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
Baylor Physical Medicine and Rehabilitation NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny Dear Patient: Please complete this questionnaire before you come for your appointment. Be sure to call us as soon
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:
Welcome to Medina Family Chiropractic and Acupuncture!
Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name: