INITIAL EVALUATION Automobile Accident. Automobile Accident
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- Mary Morgan
- 5 years ago
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1 LAST NAME: FIRST NAME: MI: Date: What brings you into our office? Automobile Accident When did this accident happen? What was your position in the vehicle? Driver Front Passenger Left Rear Passenger Middle Front Passenger Middle Rear Passenger Right Rear Passenger What was the damage to the vehicle? Mild Moderate Extensive Totaled How was the visibility on the road? Poor Fair Good And the weather was: Clear Raining Windy Foggy Snowing How did the accident happen? I hit another vehicle Another vehicle hit me I hit an object What was the point of impact on our vehicle? Left Front end Rear end Right Left front Left rear Right front Right rear Did you see the accident coming? Yes No Were you braced for the impact? Yes No Were you wearing a seatbelt? Yes No If yes, does the seatbelt have a shoulder strap? Yes No Does your vehicle have an airbag? Yes No Did it deploy during the accident? Yes No Does your vehicle have headrests? Yes No What is the position of the headrest: Even with top of my head Even with bottom of my head Middle of neck Did you strike anything inside the vehicle? Yes No
2 What inside your vehicle did you strike? Airbag Armrest Center Console Dashboard Gear shift lever/knob Headrest Rearview mirror Roof Rear window Seatback Side door Side window Wheel Windshield Other: Immediately after the accident, did you feel dazed? Yes No Did you lose consciousness? Yes No Which way was your head turned during the accident? Facing straight forward Turned to the right Turned to the left Was your head injured? Yes No Immediately after the accident, did you experience: Headache Neck Pain Low Back Pain Did you see another doctor before coming here? Yes No Did you go to a hospital after the accident? Yes No If yes, which hospital? How did you get to the hospital? Ambulance Drove self Somebody else Police Were any of the following tests performed at the hospital? X-Rays MRI CT Scan Lab Work Do you feel your condition is: Improving Staying the same Getting worse Have you lost time from work? Yes No Can you perform physical work activities: Yes No If no, because of: Pain Weakness Stress Can you go to sleep without problems? Yes No Do you awaken because of pain? Yes No Did you have sleep problems before? Yes No Activities of Daily Living Please select all activities which you are currently experiencing problems: Seeing Tasting Smelling Eating Hearing Insomnia Dressing Reading Typing Writing Grasping Using the toilet Standing Leaning Walking Stooping Squatting Loss of sexual drive Bending Twisting Carrying Lifting Pushing Restful sleeping Sitting Driving Sports Exercising Reclining Loss of concentration Irritable Riding in car Air travel Climbing Pulling Changes in personality Grooming Pinching Kneeling Reaching Nervous Tactile feeling Page 2 of 5
3 Bathing Holding Past Medical History Please select all conditions that you have had or are currently having: None Other Abdominal pain Weight Angina gain/loss Anorexia Anxiety Aortic aneurysm Arthritis Asthma Bladder infection Blood disorder Breast lumps Breast soreness Bronchitis Cancer Cardiovascular Dx Chest pain Chronic cough Chronic sinusitis Colitis Constipation Convulsions COPD Depression Dermatitis, Eczema/Rash Diabetes Difficulty in swallowing Dizziness Emphysema Endometriosis General fatigue Epilepsy Gout Excessive thirst Hand pain Fainting Headache Frequent urination Heart attack Heart disease Heartburn/Indigestion Hepatitis High Blood Pressure High PSA High triglycerides Hypertension Irregular High cholesterol Irritable colon Jaw pain Kidney disorders Kidney stones Liver / Gallbladder Problems Loss of appetite Loss of bladder control Low back pain Lung disease Mental Disease Mid back pain Muscular in Neck pain Osteoarthritis Pain in ankle or Pain in lower leg coordination foot or knee Pain in upper arm or elbow Profuse Pain in upper leg Painful urination PMS and hip Prostate problems Rapid heartbeat Renal disease Pneumonia Rheumatiod arthritis Scoliosis Shoulder pain Stroke Swelling/stiffness Thyroid disease of joints Tinnitus/ ear noises Tuberculosis Tumor Ulcer Visual disturbances Wrist pain Page 3 of 5
4 Family History Please select all conditions that run in your family: None Other Abdominal pain Weight Gain/loss Angina Anorexia Anxiety Aortic aneurysm Arthritis Asthma Bladder infection Blood disorder Breast lumps Breast soreness Bronchitis Cancer Cardiovascular Dx Chest pain Chronic cough Chronic Sinusitis Colitis Constipation Convulsions COPD Depression Dermatitis, Eczema/Rash Diabetes Difficulty swallowing Dizziness Emphysema Endometriosis Epilepsy Excessive thirst Fainting Frequent urination General fatigue Gout Hand pain Headache Heart attack Heart disease Heartburn/Indigestion Hepatitis HBP High PSA High triglycerides Hypertension Irregular High cholesterol Irritable colon Jaw pain Kidney disorders Kidney stones Liver/Gallbladder problems Loss of appetite Loss of bladder control Low back pain Lung disease Mental disease Mid back pain Muscular coordination Neck pain Osteoarthritis Pain in ankle or foot Pain in lower leg or knee Pain in upper arm or elbow Pain in upper leg and hip Painful urination PMS Pneumonia Profuse menstrual flow Prostate problems Rapid heartbeat Renal Dx Rheumatoid arthritis Scoliosis Shoulder pain Stroke Swelling/stiffness of joints Thyroid disease Tinnitus/ ear noises Tuberculosis Tumor Ulcer Visual disturbances Wrist pain Page 4 of 5
5 Surgical History Please select all surgeries that you have had in the past. None Other Abdominal Exploration ACL Reconstruction Breast Lump Cholecystectomy Abdominoplasty Abortion Adenoid Angioplasty Appendectomy Bone Fracture Repair Bunion Cosmetic Breast Carotid Artery Cataract Cervical Spine C-Section Facelift Gallbladder Gastric Bypass Heart Bypass Heart Hemorrhoid Hip Joint Replacement Hysterectomy Kidney Transplant Knee Arthroscopy Knee LASIK Eye Liposuction Lumbar Spine Prostate Surgical History was reviewed: Not contributory Hernia Repair Knee Joint Replacement Mastectomy Rotator Cuff TMJ Tonsillectomy Vasectomy Medications Please select all medications that you are currently taking: None Other Analgesics Antacids Antibiotics Antihistamines Anti-Inflammatory Arthritis Aspirin Birth Control Blood Pressure Bone Density Cancer Cholesterol Daily Vitamins Diabetes Digestion Heart Muscle Relaxers OTC Pain Steroids Thyroid Allergies Please select all items that you are allergic to: None Chemical Environmental Food Medication Seasonal Other Social History Please answer the following que tion : Married Single Widowed Divorced Separated Do you have any children? Yes No If yes, how many? Do you use: Tobacco Alcohol Coffee Page 5 of 5
SEA CLIFF CHIROPRACTIC Dr. Russell Charno
SEA CLIFF CHIROPRACTIC Dr. Russell Charno NEW PATIENT INFORMATION Name Date Address City State Zip Date of Birth Sex: Male Female Height Weight Social Security# Phone (Home) Phone (Cell) Email Occupation/
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
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
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
PERSONAL INJURY QUESTIONNAIRE
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Patient Name: Date of Birth:
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Medical History Questionnaire
Date Medical History Questionnaire Name DOB Reason for visit When did symptoms first appear Is the condition getting worse? Please rate your pain 0 1 2 3 4 5 6 7 8 9 10 No Pain Extreme Pain Please circle
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
*** ADDRESS: (If address is not provided, you MUST write Patient denied.)
PATIENT INFORMATION NORTHWEST BROWARD ORTHOPAEDICS DATE: ***E-MAIL ADDRESS: (If e-mail address is not provided, you MUST write Patient denied.) Pharmacy Name: Pharmacy Phone Number: Pharmacy Location PATIENT
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Patient s Name: Date: What is the reason for your visit today? Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone #
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
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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
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Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)
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Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #
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Health History Questionnaire:
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New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
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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
PATIENT INFORMATION FORM (WOMEN ONLY)
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New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
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