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1 Persnal Infrmatin Date: Name Address City Zip Scial Security # Cell Phne ( ) - Wrk/Hme Phne( ) - Address What is the best way t cntact yu? Phne r Text (cell phne carrier) Wh May We Thank Fr Referring Yu? Birth Date Age Sex Emergency Cntact, Name & # Emplyer Occupatin Emplyer s Address Circle One: Married / Single / Widwed / Divrced / Separated Spuse s Name Health Insurance Phne # Health Insurance ID# Grup # Research is shwing that many f ur health challenges that ccur later in life have their rigins during the develpmental years, sme starting at birth. Please answer the fllwing questins t the best f yur ability. Childhd Years Yes N Unsure Cmments (if any) Did yu have any childhd illnesses? Were yu vaccinated? Did yu have any falls frm a height ver 3 feet? (i.e. crib, bunk bed, trees) Did yu play yuth sprts? Did yu take/use any drugs? Was there any prlnged use f medicine such as antibitics r an inhaler? Were yu invlved in any physical accidents? ex. Car, Bicycle, Wrk Did yu suffer any frm f abuse? Were yu under regular Chirpractic care? Adulthd - (18 t present) D / did yu smke? Hw much? D / did yu drink alchl? Hw much? List any accidents and when. D / did yu play adult / extreme sprts? What kinds? On a scale f 1-10 describe yur level f stress (1 = nne / 10 = extreme) Occupatinal Persnal --- Nn-Occupatinal 8600 SW Salish Lane, Suite One, Wilsnville, OR Ph: , Fax
2 Name: Date: FEMALE ONLY: Is there any chance that yu may be pregnant? Yes N I understand and agree that health and accident insurance plicies are an arrangement between an insurance carrier and myself. The dctr s ffice may bill my insurance as a curtesy t me and will prepare any necessary reprts and frms (fees may apply) t assist in making cllectin frm the insurance cmpany. I clearly understand and agree that all services rendered t me are charged directly t me and that I am persnally respnsible fr payment f all fees fr service including legal fees, cllectin agency fees, and any ther expenses incurred in cllecting my accunt. I als understand and agree that if I suspend r terminate care, any fees fr services rendered t me will be immediately due and payable. I hereby authrize the dctr t treat my cnditin as he/she deems apprpriate thrugh the use f, but nt limited t, spinal adjustments. It is understd and agreed that the x-rays will remain prperty f this ffice, being n file where they may be seen at any time. The client als agrees that he/she is respnsible fr all bills incurred at this ffice. The dctr will nt be held respnsible fr any pre-existing medically diagnsed cnditins, nr fr any medical diagnsis. Client s Signature Date Legal Guardian / Print Signature 8600 SW Salish Lane, Suite One, Wilsnville, OR Ph: , Fax Page 2/2
3 Name: Date: WORK RELATED INJURY REPORT Date f Accident: Time: AM PM Lcatin: Did yu reprt the accident? Yes N T Whm? Describe the accident: If lifting, hw much weight was invlved: What psitin were yu in? Was the accident caused by smene besides yu? Yes N If yes, wh? What, if any, kind f equipment was invlved? What is the functin f this equipment? Was the accident caused by failure f equipment r a prduct? Yes N If yes, what was it? If struck by an bject, what was it? If yu fell, hw far did yu fall? Inside Outdrs What bdy parts were impacted? Head Chest Knee Shulder Hand Hip Ft Back Other What physical cnditins may have cntributed t the present injury? (Example: Icy, slippery flr, bject in the way etc.?) Did yu cntinue wrking that day? Yes N If yes, hw lng? What shift hurs were yu wrking? Describe yur jb duties: Office use nly: Hw did yu feel immediately fllwing the accident? Were yu uncnscius after the accident? Yes N If yes, hw lng? What hurt the next day? What hurt a week later (if applicable), explain? Which hspital r emergency center did yu g t after the accident? When? Hw were yu transprted? What was the name f the attending Dctr? Were x-rays taken? Yes N What was the diagnsis as yu understd it? What treatment was given, if any? Are yu n any medicatins? List: Dsage: Were yu released the same day? Yes N If nt, when were yu released? What, if any, were the recmmendatins fr hme care? Were there any ther dctrs seen fr injuries resulting frm this accident? Yes N If yes, please list the names and degrees, (DC, DO, MD), and respective diagnses and treatments: Since the accident, have yu had any additinal traumas, falls, injuries, aggravatins, etc. Yes N If yes, explain: Have yu ever injured this bdy part(s) previusly? Yes N Please explain: Office use nly:
4 Name: Date: Put a check by the symptms yu have nticed since the accident: Headaches Chest pain Dizziness Fainting Abdminal cramp Head seems t heavy Leg pain/tingling/numb Blurred visin Palpitatins Heartburn Neck pain Numbness in tes Visin prblems Indigestin Lss f smell/taste Neck stiffness Cld feet Light bthers eyes Gas/blating after Difficult urinatin Pain between shulder Walking prblems Lss f cncentratin meals Painful/excessive urine Blades Hip pain frgetfulness Pr/excessive Disclred urine Cld hands Leg pain Depressin/ appetite Pr circulatin Numbness in fingers Knee pain cnfusin Excessive thirst Bld pressure prblems Arm pain/tingling/numb Ankle pain Anxiety/nervusness Frequent nausea Irregular heartbeat Elbw pain Ft pain Irritability Vmiting Heart prblems Wrist pain Cld sweats Sleep disturbance Diarrhea Bladder truble Hand pain Difficult chewing/ Energy lss/fatigue Cnstipatin Liver truble Mid back pain clicking jaw Tired AM/PM Hemrrhids Gall bladder truble Lw back pain Dental prblems Weakness Black/bldy stl Varicse veins Shrt breath Sre thrat Buzzing/ringing ears Weight truble Ankle swelling Fever stuffed nse/sinus Earaches Menstrual Irregularity Prstate/sexual Other Allergies Hearing difficulty Menstrual Cramping dysfunctin Office use nly: Hw are yu able t perfrm the fllwing activities after the accident? Indicate by using N=Nrmal, L=Limited, D=Difficult, P=Painful, U=Unable t perfrm: Shade the areas f pain r discmfrt yu have experienced since the accident. Cughing/sneezing Pushing Getting in/ut f car Lying n back Turning ver in bed Kneeling Walking shrt distance Balancing Standing mre than 1 hur Dressing self Sexual activity Sleeping Lying n side w/knees bent Stping Lying flat n stmach Gripping Bending ver frward Pulling Sitting at table Reaching Bending frward/brushing teeth Other Climbing Office use nly: Have yu lst any time frm wrk as a result f injuries frm the accident? Yes N If yes, please list the dates: Frm t If n, are yur wrk duties restricted because f the accident? Yes N If yes, hw? Are yu being cmpensated? Yes N D yu have an attrney representing yu? Yes N Name f law firm: Attrney s name: Address: Phne: The infrmatin I have prvided is crrect and accurate t the best f my knwledge. Patient s signature: Date:
5 Neck Index Patient Name: Date: This questinnaire will give yur prvider and insurance cmpany infrmatin abut hw yur neck cnditin affects yur everyday life. Please answer every sectin by marking the ONE statement that best applies t yu. If tw r mre statements in ne sectin apply, please mark ONE that mst clsely describes yur prblem. Pain Intensity I have n pain at the mment. The pain is very mild at the mment. The pain cmes and ges and is mderate. The pain is fairly severe at the mment. The pain is very severe at the mment. The pain is wrst imaginable at the mment. Sleeping I have n truble sleeping. My sleep is slightly disturbed (less than 1 hur sleepless). My sleep is mildly disturbed (1-2 hurs sleepless). My sleep is mderately disturbed (2-3 hurs f sleepless). My sleep is greatly disturbed (3-5 hurs f sleepless). My sleep is cmpletely disturbed (5-7 hurs f sleepless). Reading I can read as much as I want with n neck pain. I can read as much as I want with slight neck pain. I can read as much as I want with mderate neck pain. I can hardly read at all because f sever neck pain. I cannt read at all because f neck pain. Cncentratin I can cncentrate fully when I want with n difficulty. I can cncentrate fully when I want with slight difficulty. I have a fair degree f difficulty cncentrating when I want. I have a great deal f difficulty cncentrating when I want. I cannt cncentrate at all. Headaches I have n headaches at all. I have slight headaches which cme infrequently. I have mderate headaches which cme infrequently. I have mderate headaches which cme frequently. I have severe headaches which cme frequently. I have headaches almst all the time. Wrk I can d as much wrk as I want. I can nly d my usual wrk but n mre. I can nly d mst f my usual wrk but n mre. I cannt d my usual wrk. I can hardly d any wrk at all. I cannt d any mre at all. Persnal Care I can lk after myself nrmally withut causing extra pain. I can lk after myself nrmally but is causes extra pain. It is painful t lk after myself and I am slw and careful. I need sme help but I manage mst f my persnal care. I need help every day in mst aspects f self-care. I d nt get dressed; I wash with difficulty and stay in bed. Lifting I can lift heavy weights withut extra pain. I can lift heavy weights but it causes extra pain. Pain prevents me frm lifting heavy weights ff the flr, but I can manage if they are cnveniently psitined ( e.g., On a table) Pain prevents me frm lifting heavy weights ff the flr, but I can manage light t medium weights if they are cnveniently psitined. I can nly lift very light weights. I cannt lift r carry anything at all. Driving I can drive my car withut any neck pain. I can drive my car as lng as I want with slight neck pain. I can drive my car as lng as I want with mderate neck pain. I cannt drive my car as lng as I want because f mderate neck pain. I can hardly drive at all because f severe neck pain. I cannt drive my car at all because f neck pain. Recreatin I am able t engage in all my recreatin activities withut neck pain. I am able t engage in my usual recreatin activities with sme neck pain. I am able t engage in mst, but nt all my usual recreatin activities because f neck pain. I can hardly d any recreatin activities because f neck pain. I cannt d any recreatin activities at all. On a scale frm 0-10 with 0= n pain and 10= wrst pain yu have ever experienced, where are yu currently? Best Average Wrst Neck Pain Scre David Duemling DC, P.C SW Salish Lane Suite One Wilsnville, OR P F nwwellnesscenter.rg
6 Back Index Patient Name: Date: This questinnaire will give yur prvider and insurance cmpany infrmatin abut hw yur back cnditin affects yur everyday life. Please answer every sectin by marking the ONE statement that best applies t yu. If tw r mre statements in ne sectin apply, please mark ONE that mst clsely describes yur prblem. Pain Intensity The pain cmes and ges and is very mild. The pain is mild and des nt vary much. The pain cmes and ges and is mderate. The pain is mderate and des nt vary much. The pain cmes and ges and is very severe. The pain is very severe and des nt vary much. Sleeping I get n pain while in bed. I get pain while in bed but it desn t prevent me frm sleeping well. My pain reduces my nrmal sleep is by less than 25% My pain reduces my nrmal sleep is by less than 50% My pain reduces my nrmal sleep is by less than 75% Pain prevents me frm sleeping at all. Sitting I can sit in any chair as lng as I like. I can nly sit in my favrite chair as lng as I like. Pain prevents me frm sitting mre than 1 hur. Pain prevents me frm sitting mre than ½ hur. Pain prevents me frm sitting mre than 10 minutes. I avid sitting because it increases pain immediately. Standing I can stand as lng as I want withut pain. I have sme pain while standing but it des nt increase with time. I can t stand fr lnger than 1 hur withut increasing pain. I can t stand fr lnger than ½ hur withut increasing pain. I can t stand fr lnger than 10 minutes withut increasing pain. I avid standing because it increases pain immediately. Walking I have n pain while walking. I have sme pain while walking but it desn t increase with time. I can t walk fr mre than 1 mile withut increasing pain. I can t walk fr mre than ½ mile withut increasing pain. I can t walk fr mre than ¼ mile withut increasing pain. I can t walk at all withut increasing pain. Persnal Care I dn t have t change my way f washing r dressing in rder t avid pain. I dn t nrmally change my way f washing r dressing even thugh it causes sme pain. Washing and dressing increases the pain but I manage nt t change my way f ding it. Washing and dressing increases the pain and I find it necessary t change my way f ding it. Because f the pain I m unable t d sme washing and dressing withut help. Because f the pain I m unable t wash and dress withut help. Lifting I can lift heavy weights withut extra pain. I can lift heavy weights but it causes extra pain. Pain prevents me frm lifting heavy weights ff the flr. Pain prevents me frm lifting heavy weights ff the flr, but I can manage if they are cnveniently psitined (e.g On a table). Pain prevents me frm lifting heavy weights ff the flr, but I can manage light t medium weights if they are cnveniently psitined. I can nly lift very light weights. Traveling I get n pain while traveling. I get sme pain while traveling but nne f my usual frms f travel make it wrse. I get extra pain while traveling but it desn t cause me t seek alternate frms f travel. I get extra pain while traveling which causes me t seek alternate frms f travel. Pain restricts all frms f travel except that dne while lying dwn. Pain restricts all frms f travel. Scial Life My scial life is nrmal and gives me n extra pain. My scial life is nrmal but increases the degree f pain. Pain has n significant affect n my scial life apart frm limiting my energetic interests (e.g., dancing) Pain has restricted my scial life and I d nt g ut very ften. Pain has restricted my scial life t my hme. I have hardly any scial life because f pain. Changing Degree f Pain My pain is rapidly getting better. My pain fluctuates but verall is definitely getting better My pain seems t be getting better but imprvement is slw. My pain is neither getting better r wrse. My pain is gradually wrsening. My pain is rapidly wrsening. On a scale frm 0-10 with 0= n pain and 10= wrst pain yu have ever experienced, where are yu currently? Best Average Wrst Back Pain Scre David Duemling DC, P.C SW Salish Lane Suite One Wilsnville, OR P F nwwellnesscenter.rg
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