Please Print Patient Information

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1 Please Print Patient Information Name Date Date of Birth Address Street Address City State Zip Home Phone Cell Phone Occupation Employer Business Phone Sex: Male Female Height Weight Are you: Married Single Domestic Partnership Divorced Separated Widowed Spouses Name: # of Children Emergency Contact Name Relationship Contact Phone Your Insurance Carrier Claim Number Other Party s Insurance Carrier Claim Number Name of Attorney_ Phone Number Do you have any special needs? How did you hear about us? Present Health Please Complete Duties Under Duress and Loss of Enjoyment Worksheets What are your health concerns? What are your goals coming in today? Who is your primary care provider? Address Phone Please list any allergies you may have Please list any medications you are currently taking Please list any supplements you are currently taking Describe your current exercise regimen Did you strike your head or any other part of your body in this accident? Chief Complaint? What makes it feel Better? What makes it feel Worse? 1

2 Have You done anything or seen anyone for this condition? Describe the pain, (circle one or more) (Sharpe, Dull, Ache, Throbing, Radiating, Numbing, Tingling, Stabbing, Burning) Headaches? (Discribe details): feeling, location,etc Medical History Have you ever been treated by a: Chiropractor Naturopathic Doctor Reflexologist Massage Therapist Acupuncturist Other alternative practitioner Family History Check applicable Father Mother Grandparent Sibling Other (Specify) Anemia Cancer Diabetes Heart Disease High Blood Pressure Stroke Epilepsy Psychological Disorder Asthma Hay fever, Hives Kidney Disease Glaucoma Tuberculosis Age at death General Health (G=Good, P=Poor) Personal History As a child, did you have any of the following diseases? Scarlet fever Rheumatic fever Diphtheria Mumps Measles German measles Other List hospitalizations or surgeries have you had with corresponding dates Have you ever been in an auto accident? When? List other injuries including falls and other traumas and when they occurred: Have you been diagnosed with any diseases or disorders and when? List childhood immunizations you received Last Tetanus shot 2

3 Review of Symptoms Weight Weight 1 yr. ago Max. Weight When Please Circle the appropriate letter next to each item based on the following: Y= a condition you have now N= never had P= a condition you have had in past Neck Pain Back Pain Lower Back Pain Extremity Pain Chest Pain Right/Left Arm Pain/ Tiingling Right/Left Leg Pain/Tingling Right/Left Foot Pain/Tingling Right/Left Hand Pain/Tingling Fingers/Toes Pain/Tingling Spasms Dizziness Vision Disturbance Motion Restriction Radiating Symptom Sleep Disruption Anxiety Night Sweats Headaches Head Injury Impaired Vision Corrected Vision Depression Tearing/Dryness Double Vision Pallectomy Cataracts Impaired Hearing Ear Ringing Earaches Frequent Colds Sinusitis Postnasal Drip Change in Taste Goiter Cough Sputum Spit up Blood Asthma Bronchitis Pneumonia Emphysema Difficulty Breathing Shortness of Breath Heart Disease Angina High Blood Pressure Fasciotomy Edema Arthroplasty (prosthetic replacement) Nausea Vomiting Constipation Blood in Stool Gas/Bloating Liver Disease Hemorrhoids Abdominal Pain Peptic Ulcer Gall Bladder Disease Pain on Urination Urinary Frequency Ligament or Tendon repair, not arthroscopy, Arthrotomy Kidney Stones Blood in Urine Joint Pain/Stiffness Arthritis Broken Bones Muscle Spasms Deep Leg Pain Thrombophlebitis Aspiration of Hematoma Fainting Seizures 3

4 Paralysis Muscle Weakness Numbness/Tingling Coordination Difficulties Depression Anxiety Mood Swings Memory Loss Drug/Alcohol Abuse Difficulty Sleeping Phobia Thyroid Problem Extremity Pain Numbness Arthrotomy, Meniscectomy, cruciate Excessive Thirst Excessive Hunger Anemia Easy Bleeding Females Only Age menses began Age menses ended Average cycle length Average bleeding length Spotting Irregular Cycles Painful Menses Birth Control Sexual Difficulties STD Breast Lumps Breast Pain Nipple Discharge PMS Symptoms Menopausal Symptoms Vaginal Dryness Vaginal Discharge/Sores Number of pregnancies Number of live births Number of miscarriages Males Only Hernias Testicular Masses Testicular Pain Sexual Difficulties STD Penile Discharge/Sores Prostate Disease Are there any additional health concerns or questions you have? Please describe a poor experience with a health practitioner you have had in the past. Please describe a good experience with a health practitioner you have had in the past. 4

5 Use the pictures below to indicate your problem areas. Use the appropriate symbol to indicate numbness, pins & needles, burning, stiffness, aching, or stabbing pain. Numbness: Pins & Needles:.-. Aching pain: ± Stabbing pain: Burning: # Stiffness: u right Please rate your discomfort on a scale of (1= mild pain, 10=the worse pain you've ever felt). Location Pain rating SEQUOIA VISIONS, INC. 5

6 PHYSICIAN PORTION ONLY List all ICD-9 codes diagnosed: List all CPT codes used: Total number of treatment dates: Last treatment date: Has whiplash (Subluxation) injuries been identified as well as individual Cervical, Thoracic and Lumbar Sprain/Strain, Ligamentous, Prolapse, Bulge, Protrusion, Herniation, Dislocation or Fracture? If so, enter whiplash (Subluxation) into NECK and BACK section. Enter each individual body part injury separately into OTHER INJURIES including Sprains/Strains. Which of the following items were identified throughout the treatment: (Last date noted could be the last treatment date or today and ongoing on the date of this report ) Initial Date Noted Last Date Noted Range of Motion Headaches Spasms Dizziness Visual Disturbance Sleep Disruption Radiating Anxiety/Depression TMJ Home Exercises Bed Rest Gym Home Traction Tens All ITEMS BELOW MUST BE VALIDATED BY A MEDICAL DOCTOR Determine future treatment determined necessary as either Probable (51 to 75% medically certain of it occurring) or Definite (76 to 100% medically certain.) Number of treatments over next: 6 months 12 months 18 months 24 months Total cost of expected treatment Is your final prognosis, Ongoing Complaints with Ongoing Treatment: Yes No Ongoing treatment would include both Passive and Active Treatments. Indicate which body part has reached MMI: % Whole Body Impairment Rating: Duties Under Duress: Work Study Domestic Duties Household Duties Hobbies Loss of Enjoyment: Work Study Domestic Duties Household Duties Hobbies Sport Sport Categories: Regionally Playing Competitive Social Any Signature of Physician Date Completed 6

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