PERSONAL INJURY VERIFICATION
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- Alfred Rich
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1 PERSONAL INJURY VERIFICATION Name Home Phone Cell Phone Address City Zip Code Birth Date Age Marital Status Employer Occupation Name of Spouse In case of emergency, please notify Phone MED-PAY Policy Holder Insurance City State Zip Policy Number Claim Number $ Amount of coverage available Adjuster Phone Number Fax Number LIABILITY (3RD PARTY) Policy Holder Insurance City State Zip Policy Number Claim Number $ Amount of coverage available Adjuster Phone Number Fax Number ATTORNEY Name Address City State Zip Phone Fax Paralegal/Contact
2 AUTO ACCIDENT PATIENT HISTORY Name Date History of the Occurrence Date of Accident Were you the DRIVER or PASSENGER What type of vehicle were you in? CAR TRUCK VAN OTHER Was it YOUR or SOMEONE ELSE s vehicle Were you wearing a seatbelt? YES or NO Your vehicle: HIT ANOTHER VEHICLE or WAS HIT In the: RIGHT LEFT REAR FRONT SIDE Type of Accident: HEAD-ON COLLISION REAR-END COLLISION BROADSIDE COLLISION NON-COLLISION Symptoms From The Accident Did you get bleeding cuts or bruises? YES or NO FRONT IMPACT(rear-end car in front) If Yes, what bleeding cuts did you get from this accident? If Yes, what bruises did you get from this accident? Please describe how you felt. Please be specific. Immediately after the accident Later that day/night The next day List of Medications Medication Purpose of Taking Medication Any Side Effects Work Status History Occupation or Job Title Have you missed time from work? YES or NO If Yes, full time off work to Returned to Modified work to ( ) Been unable to work since the accident
3 Arizona Chiropractic Neurology Center Informed Consent Document To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear. The nature of the chiropractic adjustment The primary treatment we use as a Doctor of Chiropractic is spinal manipulative therapy (SMT, CMT). We will use this procedure to treat you. We may use our hands or a mechanical instrument upon your body in such a way as you move your joints. That may cause an audible pop or click, much as you have experienced when you crack your knuckles. You may feel a sense of movement. Analysis/Examination/Treatment As part of the analysis, examination, and treatment, you are consenting to the following procedures: --Spinal manipulative therapy --Palpation --Vital Signs --Range of motion testing --Orthopedic testing --Neurological testing --Postural analysis --EMS/TENS/Galvanic --Imaging and Lab studies as indicated --hot/cold therapy --Stretching --massage therapy --exercise rehabilitation --Microcurrent --low level laser therapy --SSEP --Functional medicine/supplements --Other The material risks inherent in chiropractic care As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and physiotherapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strains, ligament sprains, cervical myelopathy, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to complications including stroke (CVA). Some patients will feel some stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me. Cauda Equina Syndrome has been reported in rare cases which requires immediate medical care. The probability of those risks occurring Statistically, Chiropractic Care has been demonstrated to be one of the safest of all healthcare practices. Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for during the raking of your history and examination. CVA has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur one in five million cervical adjustments. Two major studies (2008, 2015) showed there was not causation between CMT and CVA but rather the patient was already presenting with arterial dissection. The other complications are also generally described as rare. The availability and nature of other treatment options Other treatment options for your condition may include: -Self-administered, over-the-counter (OTC) analgesics, ice, head or rest. -Medical care and prescription drugs such as anti-inflammatories, muscle relaxants and pain killers. -Hospitalization/Surgery If you choose to use on of the above noted other treatment options, you should be aware that there are severe risks associated with these treatments. Many patients taking OTC NSAID s such as Ibuprofen and Acetaminophen are not aware that every year there are thousands of deaths associated with their use. No medicine should ever be taken without discussing their side effects and inherent statistical danger with their primary care physician or pharmacist. The PDR is also a good reference regarding pharmaceutical use. The risks and dangers attendant to remaining untreated Remaining untreated may create adhesions or scar tissue that can weaken the area and reduce mobility. Further joint degeneration may occur as well as the development of chronic pain syndromes. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. I have read or have had read to me the above explanation of the chiropractic adjustment and related treatment. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment. DATED: PATIENTS NAME: SIGNATURE SIGNATURE OF PARENT OR GUARDIAN (if minor) DATED: DOCTOR S NAME: SIGNATURE
4 ASSINGMENT AND INSTRUCTION FOR DIRECT PAYMENT TO DOCTOR PRIVATE AND GROUP ACCIDENT AND HEALTH INSURANCE Patient: Employer: Claim #: I hereby instruct and direct that Insurance Company to pay by check made out and mailed to: Dr. Trevor Berry AND Dr. Russell Teames 3800 W. Ray Road Suite 12 Chandler, AZ The professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay any balance of said professional service charges over and above this insurance payment. A photocopy of this Assignment shall be considered as effective and valid as the original. I authorize the release of any information pertinent to my case to any Insurance Company, Adjuster, or Attorney, or for the purpose of filing a Health Care Lien. For all Personal Injury cases, a medical lien/release of lien will be filed and copies will be sent to you. I also authorize Doctor to complain to Insurance Commissioner on my behalf for any reason. POLICY: Dr. Trevor Berry and Dr. Russell Teames will only file to Major Medical Carriers during Personal Injury Care if a) He is not credentialed with that company and/or b) If there are no other means for Settlement Re-Imbursement, ie: 3 rd Party Liability, Med Pay, etc. Dated at this day of 20 Signature of Policy Holder/Claimant Witness
5 COMPLAINTS Print Name Please answer all of the below by putting a checkmark in the appropriate box. Date NECK OR CERVICAL SPINE NONE MILD MODERATE SEVERE Neck Pain and Soreness Loss of Pain with Movement Shoulder Pain Pain/Numbness/Tingling in Arm or Hand Weakness in Arm or Hand MID-BACK OR THORACIC SPINE NONE MILD MODERATE SEVERE Mid-back Pain Rib or Chest Pain LOWER BACK OR LUMBAR SPINE NONE MILD MODERATE SEVERE Lower Back Pain and Soreness Loss or Pain with Movement Pain into Hips or Buttocks Pain into Legs, Knees, or Feet Numbness/Burning in Legs or Feet OTHER COMPLAINTS NONE MILD MODERATE SEVERE Headaches Visual Disturbances/Blurry Vision Ringing or Buzzing in Ears Nausea or Vomiting Difficulty Breathing Dizziness Recent Weight Loss Bowel or Bladder Dysfunction OTHER INJURY AREAS NONE MILD MODERATE SEVERE AGGRAVATED BY NONE MILD MODERATE SEVERE Coughing Sneezing Prolonged Sitting Prolonged Standing Prolonged Riding in a Car Lying on Stomach Patient Signature Doctor Signature
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8 HEADACHE DISABILITY INDEX Patient Name Date INSTRUCTIONS: Please CIRCLE the correct response: 1. I have headache: (1) 1 per month (2) more than 1 but less than 4 per month (3) more than one per week 2. My headache is: (1) mild (2) moderate (3) severe Please read carefully: The purpose of the scale is to identify difficulties that you may be experiencing because of your headache. Please check off YES, SOMETIMES, or NO to each item. Answer each question as it pertains to your headache only. YES SOMETIMES NO E1. Because of my headaches I feel handicapped. F2. Because of my headaches I feel restricted in performing my routine daily activities. E3. No one understands the effect my headaches have on my life. F4. I restrict my recreational activities (eg, sports, hobbies) because of my headaches. E5. My headaches make me angry. E6. Sometimes I feel that I am going to lose control because of my headaches. F7. Because of my headaches I am less likely to socialize. E8. My spouse (significant other), or family and friends have no idea what I am going through because of my headaches. E9. My headaches are so bad that I feel that I am going to go insane. E10. My outlook on the world is affected by my headaches. E11. I am afraid to go outside when I feel that a headaches is starting. E12. I feel desperate because of my headaches. F13. I am concerned that I am paying penalties at work or at home because of my headaches. E14. My headaches place stress on my relationships with family or friends. F15. I avoid being around people when I have a headache. F16. I believe my headaches are making it difficult for me to achieve my goals in life. F17. I am unable to think clearly because of my headaches. F18. I get tense (eg, muscle tension) because of my headaches. F19. I do not enjoy social gatherings because of my headaches. E20. I feel irritable because of my headaches. F21. I avoid traveling because of my headaches. E22. My headaches make me feel confused. E23. My headaches make me feel frustrated. F24. I find it difficult to read because of my headaches. F25. I find it difficult to focus my attention away from my headaches and on other things. OTHER COMMENTS: Examiner With permission from: Jacobson GP, Ramadan NM, et al. The Henry Ford Hospital headache disability inventory (HDI). Neurology 1994;44:
9 ACNC Concussion Symptom Score Sheet If you are unsure of a question or do not feel well enough to complete this form you may leave it blank and ask for assistance from one of our staff members. Thank you Name: DOB: Date of Injury: Today s Date: (0=No Symptoms) (1-2=Very Mild) (3-4=Mild) (5-6=Moderate) (7-8=Severe) (9-10=Worst Ever) Please circle the number that best matches the way you feel right now. Headache: Nausea: Vomitting: Balance Problems: Dizziness: Fatigue/Drowsiness: Trouble Falling Asleep: Needing More Sleep: Sensitivity to Light: Sensitivity to Noise: Irritability: Sadness: Nervousness: Feeling Emotional: Numbness or Tingling: Feeling Slowed Down: Feeling Mentally Foggy: Trouble Concentrating: Memory Issues: Visual Problems:
10 Name Date Date of Injury Concussion Questionnaire Please answer the following questions in good detail: Have you ever had from MONO, STREP, MOLD EXPOSURE, LYME, AUTOIMMUNITY? (Circle all that apply) Specifically, what symptoms or stressful situations were going on BEFORE, DURING, and IMMEDIATELY FOLLOWING your concussion? (examples- I was going through a divorce, then I got a 24 hour gut bug, I was under immense amounts of stress at work/school, I was dealing with IBS, constipation/diarrhea, anxiety/depression, and autoimmune condition, diabetes, type A personality, I was on day 20 of my menstrual cycle) BEFORE DURING IMMEDIATELY FOLLOWING
PERSONAL INJURY VERIFICATION
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General Information: (Circle One) (Circle One) Primary Insured's Information Skip if you are primary
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HEADACHE HISTORY. Indicate the area of your head where your headaches seem to be concentrated. Please check those that apply:
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Extended Health Care Company Do you need any help retaining information about your health insurance coverage? Yes No
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Today s Date: What are your health goals? Symptom relief and preventing its return 100% optimum health and wellbeing on every level available to me
Today s : MHSC REGISTRATION # (6 DIGIT) (9 DIGIT) First Name: Last Name: I am a Male/Female (circle) Birthday (d/m/y): / / Current Age: Street Address: City: Province: Postal Code: Home #: Work #: Cell
Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
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CIRCLE ALL CURRENT PROBLEMS YOU HAVE
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New Practice Member Application
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3. How Long Has This Been An Issue?
NEW PATIENT INTAKE FORM Aspire Chiropractic 124 W Harwood Rd. Ste. B Hurst, TX 76054 Name: Occupation: DOB: Age: Sex: Male Female Employer: Marital Status: Single Married Other Name/Age of Kids: Phone:
Who may we thank for referring you?
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Puritz Chiropractic Center Patient Health Questionnaire
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DR. ANN IZARD, B.COMM, DC DOCTOR OF CHIROPRACTIC 4353 HASTINGS STREET BURNABY, BC V5C 2J7 TEL: 604.293.2941 FAX: 604.298.2941 WWW.BHIHC.COM WWW.ANNIZARD.COM FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET
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LIST YOUR HEALTH CONCERNS BELOW
Name Date / / Age Male/Female Address City State Zip Phone: Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single/Married/Divorced/Widowed Spouse s Name Number of Children
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LOCATION COMING SOON Lakewood Ranch, FL 32402 941.877.1507 Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Date of Birth / / Employer s Name Position Single
Reason forappointment:
Patient Information Date / / Patient Name (last, first) Sex: Male / Female Home Phone # ( ) Cell Phone # ( ) E-Mail Address Address City State Zip Code Date of Birth / / Age Occupation Who Referred You
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KEY TO LIFE CHIROPRACTIC
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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
Address City State Zip Code
Name Cell Phone Address City State Zip Code Date of Birth / / Male/Female Age Email SS# Number of Children Name of Children Employer Type of Work Marital Status Married Single Divorced Separated Widowed
Adult Health Questionnaire
Health for Life Chiropractic At Cloverdale Mall Unit #143-250 The East Mall Etobicoke, ON, M9B 3Y8 416-232-1822 416-232-0060 Dr. Chrystopher Sly B.Sc, D.C. Dr. Jesse Cracknell B.A., D.C. Adult Health Questionnaire
HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC Today s Date: HRN: PATIENT DEMOGRAPHICS Name: DOB: Age: Male Female Address: City: State: Zip: E-mail: Home
Birth Date Age Social Security # Marital Status (circle) Have you had chiropractic care in the past? Yes No If yes, how long ago?
136 Wilson Pike Circle Brentwood, TN 37027 NEW PATIENT INFORMATION Please complete ALL questions below unless otherwise indicated. First Name Last Name Date Street Address City State Zip Cell Phone Provider
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Address
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Email Address Do you have Medicaid? Y / N (present your card to
CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
DR. ANN IZARD, B.COMM, DC DOCTOR OF CHIROPRACTIC 4353 HASTINGS STREET BURNABY, BC V5C 2J7 TEL: 604.293.2941 FAX: 604.298.2941 WWW.BHIHC.COM WWW.ANNIZARD.COM FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET
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
Patient Health Record
PERSONAL INFORMATION: Patient Health Record River Falls Chiropractic Name: Age: Date: Address: City/State/ Zip: Home Phone #: ( ) - Work Phone #: ( ) - Cell Phone #: ( ) - Email Address: Male Female: DOB:
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
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM Which Chiropractor are
Liberty Chiropractic Clinic Scarsdale Blvd., Houston, TX
Liberty Chiropractic Clinic, -6154 Patient's Name Patient's Address City State Zip Code Age D.O.B. Single Married Divorced Widowed No. of children Occupation Employer Home Phone Work Phone Cell Phone Email
Luker Chiropractic Health Questionnaire
Luker Chiropractic Health Questionnaire Name: D.O.B.: Address: City: State: Zip: Home Phone: Cell: Email: Male/Female Marital Status: M W D S Age: SS# Occupation: Employer: Spouse Name: # of Children:
Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)
Name_ Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon) For reminders do you prefer Phone Calls, Text Messages or Emails? CALL ME / TEXT ME / EMAIL ME Email Address
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy Terms of Acceptance When a patient seeks health care in our office and we accept a patient for such care, it is essential the patient
LIST YOUR HEALTH CONCERNS BELOW
Date / / HEALTH PROFILE T C E X Name D.O.B. / / Age Male/Female Address City State Zip Phone: Home Cell Cell Phone Carrier: Email Address Occupation Employer s Name _ Single / Married / Divorced / Widowed
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
Physical Evidence Chiropractic 7035 Beracasa Way, Suite 103 Boca Raton Florida, Phone# (561) Fax# (561)
7035 Beracasa Way, Suite 103 Boca Raton Florida, 33433 Phone# (561)674-1217 Fax# (561)361-4999 Date File # PERSONAL HISTORY Last Name First Name middle Address City State Zip Date of Birth Age Social Security
History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
APPLICATION FOR CARE AT CORE CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT CORE CHIROPRACTIC Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU!
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU! NAME DATE ADDRESS Gender CITY, PROVINCE HOME PHONE E MAIL POSTAL CODE DATE OF BIRTH (D/M/Y)
Chiropractic Case History/Patient Information
Family Chiropractic and Wellness. 1 Chiropractic Case History/Patient Information Date: Patient # Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Birth
APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS HRN: Name: Birth Date: - - Age: o Male o Female Address: City: State:
Rupp Chiropractic FAMILY PHYSICIAN FEMALES: ARE YOU PREGNANT, OR A CHANCE YOU MIGHT BE PREGNANT? YES / NO HOW WERE YOU REFERRED TO OUR OFFICE?
PATIENT INFORMATION NAME DATE ADDRESS CITY STATE ZIP HOME # CELL # WORK # E MAIL ADDRESS SOCIAL SECURITY # I WOULD LIKE TO RECEIVE EMAIL APPOINTMENT REMINDERS [YES] [NO] RACE: AMERICAN INDIAN ALASKA NATIVE
Patient Information Form
Patient Information Name: First Middle Last Address: City: State: Zip: Telephone: Home Cell Work Date of Birth: Social Security Number: (SSN is only needed if getting super-bills for potential insurance