Accident Information How were you injured? Auto W/C Slip & Fall Auto/While on Job Cab Bus Motorcycle Pedestrian

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Annice Hood
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Version 05/20/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Please Print Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone

1 Version 05/20/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Please Print Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone Cell Phone Address Occupation Unemployed Employer Business Phone Employer Address Length of Employment Second Employer Phone: Second Employer Address Sex: Male Female Height Weight Dominant Hand: Left Right Race: African American Asian Caucasian Hispanic Other Are you: Married Single Domestic Partnership Divorced Separated Widowed Spouse s Name: # of Children Emergency Contact Name Relationship Contact Phone Health Insurance Carrier Waiver Signed Health Insurance Address Policy Number Group Number Policy Holder DOB of Policy Holder Employer of Policy Holder Relationship Who is your Primary Care Provider? Phone: Primary Care Provider Address Name of nearest relative not living with you: Phone: Have you ever been seen previously for the current condition? Yes No If yes, where? Phone Number: Accident Information How were you injured? Auto W/C Slip & Fall Auto/While on Job Cab Bus Motorcycle Pedestrian Date of Injury What State? Brief description of how accident happened: Did you strike your head or any other part of your body in this accident? Have you been able to work since your accident? Yes No Last day worked? Has an out of work slip been issued to you? Yes No 1

2 Version 05/20/2015 Auto Accident: Were you the driver? Passenger? Seat Belted? Yes No Has this accident been reported to the auto insurance company? Yes No Driver s Name Policy Holder s Name Policy Holder s car insurance carrier Policy Holder s Phone Number PIP Adjuster: Phone #: PIP Claim #: IF YOU DO NOT OWN A MOTOR VEHICLE: Does anyone else in household own motor vehicles? Yes No Workers Compensation: Date of Injury WC Carrier Claim# Who is/was your employer at the time of injury? Employer Address (City) (State) (ZIP) Employer Phone Number Supervisor s Name Have you filed a First Report of Injury with your employer? Yes No Prior Accidental Injuries WHAT TYPE OF ACCIDENT? WHEN? WHERE? WHAT INJURED? TREATED BY? DATE OF LAST TREATMENT FULL OR PARTIAL RECOVERY? Auto Work Comp Auto/While on Job Cab Bus Motorcycle Pedestrian Auto Work Comp Auto/While on Job Cab Bus Motorcycle Pedestrian Auto Work Comp Auto/While on Job Cab Bus Motorcycle Pedestrian 2

3 Present Health Version 05/20/2015 Why do you need an evaluation today? Check the appropriate area and briefly explain. (Examples-pain, numbness, tingling, burning, weakness) Neck Shoulder Elbow Wrist Low Back Hip Knee Leg Ankle Foot Other (please specify): When did the symptom(s) begin? How did the pain symptom(s) start? Check the appropriate response or explain. Suddenly Gradually Twisting Pulling Fall Lifting Bending Hit by Object Sports No apparent Cause Did you go to the hospital, E.R., or Urgent Care? Yes Date(s) No Name of hospital, E.R. or Urgent Care: Did you have X-rays, MRI, CT Scan, or other diagnostic testing? Have you been treated anywhere else for this accident? Yes No If yes, where? Phone Number: Have you been injured prior to this accident? Yes No Have you ever had a Disability Rating for a previous accident? Yes No Please list any medications you are currently taking Please list any supplements you are currently taking Please list any allergies (including drug and latex allergies-see questionnaire below) you may have Latex Allergies Do you ask for LATEX-FREE gloves during a doctor visit, such as the GYN? Do you get a rash when wearing Household Cleaning Gloves? Do you get a reaction from Condoms? Do you have a reaction Blowing Up Balloons, such as tingling lips, difficulty breathing, or rash? Does the Elastic in your Undergarments cause a rash? Have you ever been tested for a LATEX allergy? Have you ever been told you have a LATEX allergy? 3

4 Pain Description Please rate your pain on a scale of (1= mild pain, 10=the worse pain you've ever felt) Areas of Injury Pain Scale Areas of Injury Pain Scale Areas of Injury Head Left Shoulder Right Shoulder Neck Left Elbow Right Elbow Upper Back Left Wrist/Hand Right Wrist/Hand Lower Back Left Knee Right Knee Hips Left Ankle/Foot Right Ankle/Foot Version 05/20/2015 Pain Scale 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 4

5 Loss of Enjoyment/Duties Under Duress Summary Complete the following questionnaire as it relates to how your injury(s) affect your performance of your living and work duties. Place a check in front of the day-to-day living or work duties that are painful or difficult for you to perform as a result of the injuries you sustained. Then check mark the appropriate box designating reason for difficulty. Include those duties/responsibilities, which require that you reduce the time you are capable of performing them. Job description: N/A Work Reason for the Difficulty/Limitation Lifting Increased Pain Restricted Movement Weakness Cannot Perform Bending Increased Pain Restricted Movement Weakness Cannot Perform Sitting Increased Pain Restricted Movement Weakness Cannot Perform Walking Increased Pain Restricted Movement Weakness Cannot Perform Computer Duties Increased Pain Restricted Movement Fatigue Cannot Perform Other: Increased Pain Restricted Movement Fatigue Cannot Perform N/A Studies/School Reason for the Difficulty/Limitation Lifting Increased Pain Restricted Movement Weakness Cannot Perform Bending Increased Pain Restricted Movement Weakness Cannot Perform Sitting Increased Pain Restricted Movement Weakness Cannot Perform Walking Increased Pain Restricted Movement Weakness Cannot Perform Computer Duties Increased Pain Restricted Movement Fatigue Cannot Perform Studying Increased Pain Restricted Movement Fatigue Cannot Perform Other: Increased Pain Restricted Movement Fatigue Cannot Perform N/A Domestic Duties Reason for the Difficulty/Limitation Vacuuming Increased Pain Restricted Movement Fatigue Cannot Perform Taking Care of Kids Increased Pain/Anxiety Restricted Movement Fatigue Cannot Perform Cleaning Increased Pain Restricted Movement Fatigue Cannot Perform Preparing Meals Increased Pain Restricted Movement Fatigue Cannot Perform Other: Increased Pain/Anxiety Restricted Movement Fatigue Cannot Perform N/A Household Duties Reason for the Difficulty/Limitation Yardwork Increased Pain Restricted Movement Fatigue Cannot Perform Transportation Increased Pain/Anxiety Restricted Movement Fatigue Cannot Perform Shopping Increased Pain/Anxiety Restricted Movement Fatigue Cannot Perform Taking Out Trash Increased Pain Restricted Movement Weakness Cannot Perform Other: Increased Pain Restricted Movement Weakness Cannot Perform N/A Sports Reason for the Difficulty/Limitation Name Sport: Increased Pain Restricted Movement Weakness Cannot Perform Pre-Accident Level of Participation: Socially Competitively Professional Are you Pregnant? (Women Only) Social History 5

6 Yes No Do you Live Alone? Drugs/Alcohol: History of Substance Abuse? Do you drink Alcoholic Beverages? Have you ever smoked Cigarettes? If you smoked in the past, how long has it been since you stopped? 0-3 months 3-6 months 6-12 months Over a year ago Exercise: Do you Exercise? Daily Weekly Monthly Rarely Never What type of Exercise? Walking Running Swimming Weight Lifting Aerobics Other Do you have Children? Family History Has your Father ever had/have: Has your Mother ever had/have: Have your Siblings ever had/have: Have your Grandparents ever had/have: Has your Daughter(s) ever had/have: Has your Son(s) ever had/have: 6

7 Review of Systems Weight Weight 1 yr. ago Max. Weight When Head Symptoms Dizziness Headaches Head Injury Blurred Vision Seeing Spots Eye Tearing/Eye Dryness Double Vision Cataracts Eye Glasses/Contact Lenses Impaired Hearing Ear Ringing Ear Aches Respiratory Symptoms Frequent Colds Sinusitis Post Nasal Drip Change in Taste Cough Sputum Spit up Blood Difficulty Breathing Shortness of Breath Asthma Bronchitis Pneumonia Emphysema Digestive Symptoms Nausea Vomiting Constipation Blood in Stool Gas/Bloating Hemorrhoids Belly Pain Peptic Ulcer Gall Bladder Disease Genitourinary Symptoms Pain when Urinating Frequent Urination Kidney Stones Blood in Urine Hernia Testicular Pain/Mass Sexual Difficulties Prostate Disease Irregular Menses Painful Menses Spotting Breast Lumps/Pain/Discharge Currently Pregnant Muscle/Joint Symptoms Joint Pain/Stiffness Arthritis Broken Bones Muscle Spasms Deep Leg Pain Neck Pain Back Pain Lower Back Pain Extremity Pain Chest Pain Right/Left Arm Pain/Tingling Right/Left Leg Pain/Tingling Right/Left Foot Pain/Tingling Right/Left Hand Pain/Tingling Fingers/Toes Pain/Tingling Spasms Nerve Symptoms Fainting Seizures Convulsions Paralysis Weakness Numbness/Tingling Dropping Things Tripping Emotional Symptoms Depression Anxiety Mood Swings Memory Loss Difficulty Sleeping Fear of Driving Nightmares Flashbacks Claustrophobic 7

8 Heart Symptoms Heart Disease Angina Swelling of Legs/Feet Palpations Chest Pain High Blood Pressure Murmur Other Symptoms New Lumps/Bumps Easy Bleeding/Bruising Fever/Chills Night Sweats Weight Loss/Gain Diseases Thyroid Disease Sexually Transmitted Disease Anemia Diabetes HIV Hepatitis Scarlet Fever Please list any surgeries and the dates they were performed: Date Surgery 8

9 Provider Signature: Date 9

Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone

Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Please Print Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone Cell Phone E-Mail Address