AUTO ACCIDENT QUESTIONNAIRE

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AUTO ACCIDENT QUESTIONNAIRE Name Date of Birth Age Address City State Zip NATURE OF ACCIDENT: 1. Date of Accident Time of Day (AM / PM) 2. Were you the ( ) Driver or ( ) Passenger? 3. If a passenger were you in the ( ) Front or ( ) Back Seat? 4. Number of people in your vehicle? Other Vehicle? 5. In which direction were you headed? ( ) North ( ) South ( ) East ( ) West on: Street City State 6. What direction was the other vehicle headed? ( ) North ( ) South ( ) East ( ) West on (name of street): 7. Were you struck from? ( ) Behind ( ) Front ( ) Left Side ( ) Right Side 8. Were you wearing a seat belt? ( ) Yes ( ) No 9. Were the police notified? ( ) Yes ( ) No 10. Are you the owner of the car? ( ) Yes ( ) No If not, who is? 11. State how the accident happened in your own words: 12. Describe in your own words what happened to you upon impact: 1 @2017 Carmel Wellness Center Inc. All Rights Reserved

13. Please describe how you felt: a. DURING the accident: b. IMMEDIATELY AFTER the accident: c. THE NEXT DAY: 14. What are your present complaints and symptoms: 15. Are your symptoms improving or getting worse since the accident? (please explain) 16. CHECK SYMPTOMS YOU HAVE NOTICED SINCE ACCIDENT: 16. PLEASE MARK ON FIGURES: Headache Irritability Numbness in Toes Neck Pain Chest Pain Shortness of Breath Neck Stiff Dizziness Fatigue Sleeping Problems Head Seems Too Heavy Depression Back Pain Pins & Needles in Arms Lights Bother Eyes Nervousness Pins & Needles in Legs Loss at Memory Tension Numbness in Fingers Ears Ring Face Flushed Feet Cold Buzzing in Ears Hands Cold Loss of Balance Stomach Upset Fainting Constipation Loss of Smell Cold Sweats Loss of Taste Fever Diarrhea MARK PAIN AREA +++ Burning 000 Stabbing --- Sharp 111 Constant 17. Did you have any similar complaints BEFORE the accident? ( ) Yes ( ) No If yes, please describe in detail: 18. Where were you taken after the accident? _ 19. Have you been treated by another doctor since the accident? ( ) Yes ( ) No If yes, please list doctor's name and address. What type of treatment did you receive? Are you still being treated? ( ) Yes ( ) No 2 @2017 Carmel Wellness Center Inc. All Rights Reserved

20. Did you get bleeding cuts or bruises? ( ) Yes ( ) No 21. Since the injury, are your symptoms? ( ) Improving ( ) Getting Worse ( ) Same 22. What was the approximate damage done to your car? 23. Have you missed any time from work? ( ) Yes ( ) No If yes, the name of your employer: Have you returned to work? ( ) Yes ( ) No If yes, date returned: 24. Do you have an attorney for this case? ( ) Yes ( ) No if Yes, Who? Name Address City/State/Zip 25. Were there any witnesses? ( ) Yes ( ) No If yes, list name(s): INSURANCE INFORMATION: YOUR INSURANCE INFORMATION Name _ Phone # Policy # Address Adjusters Name: City/State/Zip OTHER DRIVER'S INSURANCE INFORMATION: Other Driver s Name Insurance Company Phone # Policy # Address Adjusters Name: City/State/Zip Which insurance company is responsible for your bill? ( ) Mine ( ) Other Driver Patient s Signature Date 3 @2017 Carmel Wellness Center Inc. All Rights Reserved

DOCTOR'S LIEN AND INSTRUCTIONS TO COUNSEL I, the undersigned, understand that all past, present and future bills incurred at the Doctor/Clinic noted below, are my responsibility for payment. I hereby ratify my agreement to pay all bills incurred during my health care at this Clinic. In consideration for the below named Doctor/Clinic having agreed to treat me without payment at the time of service and enabling me to obtain treatment for my accident/injury/illness, without financial hardship, I give you a lien on any settlement, claim, judgment, verdict or result of said accident/injury/illness and I agree to irrevocably instruct my attorney to pay you in full from any proceeds of settlement, claim or judgment related this accident/injury/illness. I also understand that if the settlement does not cover my entire bill at this Clinic, I am still responsible for the remainder and the payment by me of this bill is not contingent on any settlement, claim or judgment which I may eventually recover. Furthermore, in consideration for the below named Doctor/Clinic refraining from attempting to collect immediate payment for services rendered for my accident/injury/illness, I do hereby waive and toll any applicable statute of limitations on the collection of my account until I notify the Doctor/Clinic of the conclusion of my efforts to obtain a settlement or judgment through the assistance of my attorney and for a period of three (3) months thereafter. Patient s Name (Please Print) Patient s Address Patient s Signature/Date * * * * INSTRUCTIONS TO COUNSEL Date of Injury I do hereby irrevocably instruct you, my Attorney, named below, to pay Doctor/Clinic named above in full for services to me for my accident/injury/illness from any proceeds of settlement, claim or judgment regarding said accident/injury/illness. You are to pay the Doctor/Clinic prior to distributing any proceeds to me and I instruct you not to attempt to reduce by means of negotiation my doctor's bill for the services that have been provided to me for the accident/injury/illness which I have agreed to pay in full. Full Name Patient s Signature Attorney Name * * * * ATTORNEY'S ACCEPTANCE OF LIEN Date Being the attorney of record or authorized representative, I acknowledge receipt of my client's instructions to Counsel and Lien and agree to honor the same. Attorney Name Date 4 @2017 Carmel Wellness Center Inc. All Rights Reserved

BACK INDEX PATIENT NAME LAST FIRST MID DATE This questionnaire will give the doctor information as to how your back condition affects your everyday life. Please answer every section and mark only the one box that applies to you. It two statements in one section relate to you. Please mark the box which most closely describes your problem. Section 1 - Pain intensity The pain comes and goes and is very mile. The pain is mild and does not very much. The pain comes and goes and is moderate. The pain is moderate and does not very much. The pain comes and goes and is very severe. The pain is very severe and does not very much. Section 6 - Standing I can stand as long as I want without pain. I have some pain while standing but it does not increase with time. I cannot stand for longer than 1 hour without increasing pain. I cannot stand for longer than 1/2 hour without increasing pain. I cannot stand for longer than 10 minutes without increasing pain. I avoid standing because it increases pain immediately. Section 2 - Personal Care Section 7 - Sleeping I do not have to change my way of washing or dressing I get no pain in bed. in order to avoid pain. I get pain in bed but it does not prevent me from sleeping well. I do not normally change my way of wasting or dressing Because of pain my normal night's sleep is reduced by less man 25%. even though it causes some pain. Because of pain my normal night's sleep is reduced by less than 50%. Washing and dressing increase the pain but I manage not Because of pain my normal night s sleep is reduced by less than 75%. to change my way of doing it. Pain prevents me from sleeping at all. Washing and dressing increase the pain and I find it necessary to :mange my way of doing it Section 8 - Social Life Because of the pain I am unable to do some washing and My social life is normal and gives me no extra pain. dressing without help. My social life is normal but increases the degree of pain. Because of the pain I am unable to do any washing and Pain has no significant affect on my social life apart from dressing without help. limiting my more energetic interests (e.g. dancing, etc.). Pain has restricted my social life and I do not go cut very often. Section 3 - Lifting Pain has restricted my social life to my home. I can lift heavy weights without extra pain. I have hardly any social life because of the pain. I can lift heavy weights, but it causes extra pain. Pain prevents me from fitting heavy weights off the floor Section 9 - Traveling Pain prevents me from lifting heavy weights off the floor, but I I get no pain while traveling. manage it they are conveniently positioned (e.g. on a table). I get some pain while traveling but none of my usual forms of travel Pain prevents me from lifting heavy weights but I can manage make it any worse. light to medium weights if they are conveniently positioned. I get extra pain while traveling but it does not cause me to seek I can lift only very lightweights. alternate forms of travel. I get extra pain while traveling which causes me to seek alternate Section 4 - Walking Forms of travel. I have no pain while walking. Pain restricts all forms of travel except that done lying down. I have some pain while walking but it does not increase with Pain restricts all forms of travel. distance I cannot walk more than one mile without increasing pain. I cannot walk more than 1/2 mile without increasing pain. Section 10 - Changing degree of pain I cannot walk more than 1/4 mile without increasing pain. My pain is rapidly getting better. I cannot walk at all without increasing pain. My pain fluctuates but overall is definitely getting better. My pain seems to be getting better but improvement is slow at present Section 5 - Sitting My pain is neither getting better or worse. I can sit in any chair as long as I like. My pain is gradually worsening. I can only sit in my favorite chair as long as I like. My pain is rapidly worsening. Pain prevents me from sitting more than 1 hour. Pain prevents me from sitting more than 1/2 hour. Pain prevents me from sitting more than 10 minutes. I avoid sitting because it increases pain immediately. 5 @2017 Carmel Wellness Center Inc. All Rights Reserved

NECK INDEX PATIENT NAME LAST FIRST MID DATE This questionnaire will give the doctor information about now your neck condition affects your everyday life. Please answer every section and mark only the one box that applies to you. If two statements in one section relate to you, please mark the box which most closely describes your problem. Section 1 - Pain intensity I have no pain at the moment The pain is very mild at the moment. The pain is moderate at the moment. The pain is fairly severe at the moment The pain is very severe at the moment. The pain is the worst imaginable at the moment. Section 6 - Concentration I can concentrate fully when I want to with no difficulty. I can concentrate fully when I want to with slight difficulty. I have a fair degree of difficulty concentrating when I want to. I have a lot of difficulty concentrating when I want to. I have a great deal of difficulty concentrating when I want to. I cannot concentrate at all. Section 2 - Personal Care (Washing, Dressing, etc.) I can look after myself normally without causing extra pain. I can look after myself normally but it causes extra pain. It is painful to look after myself and i am slow and careful. I need some help but I manage most of my personal care. I need help every day in most aspects of self care. I do not get dressed; I wash with difficulty and stay in bed. Section 7 - Work I can do as much work as I want to. I can only do my usual work, but no more. I can only do most of my usual work, but no more. I cannot do my usual work. I can hardly do any work at all. I cannot do any work at all Section 3 - Lifting I can lift heavy weights without extra pain. I can lift heavy weights, but it causes extra pain. Pain prevents me from lifting heavy weights off the floor. but I can manage if they are conveniently positioned, for example on a table. Pain prevents me from lifting heavy weights off the floor, but l can manage light to medium weights if they are conveniently positioned. I can lift only very light weights. I cannot lift or carry anything at all. Section 4 - Reading I can read as much as I want with no neck pain. I can read as much as f want with slight neck pain. I can read as much as I want with moderate neck pain. I cannot read as much as I want because of moderate neck pain I can hardly read at all because of severe neck pain. I cannot read at all. Section 5 - Headaches I have no headaches at all. I have slight headaches which come infrequently. I have moderate headaches which come infrequently. I have moderate headaches which come frequently. I have severe headaches which come frequently. I have headaches almost all the time. Section 8 - Driving I can drive my car without any neck pain. I can drive my car as long as I want with slight neck pain. I can drive my car as long as I want with moderate neck pain. I cannot drive my car as long as I want because of moderate neck pain I can hardly drive at all because of severe neck pain. I cannot drive my car at all. Section 9 - Sleeping I have no trouble sleeping. My sleep is slightly disturbed (less than 1 hr. sleepless). My sleep is mildly disturbed (1-2 hrs. sleepless). My sleep is moderately disturbed (2-3 hrs. sleepless). My sleep is greatly disturbed (3-5 hrs. sleepless). My sleep is completely disturbed (5-7 hrs_ sleepless). Section 10 - Recreation I am able to engage in all my recreation activities with no neck pain at all. I am able to engage in all my recreation activities with some neck pain. I am able to engage in most but not all my recreation activities because of neck pain. I am only able to engage in a few of my usual recreation activities because of neck pain. I can hardly do any recreation activities because of neck pain. I cannot do any recreation activities at all. 6 @2017 Carmel Wellness Center Inc. All Rights Reserved

AUTHORIZATION FOR RELEASE I authorize payment of medical benefits to Carmel Wellness for services rendered. I authorize the release of any information you deem appropriate concerning my physical condition to any insurance company, attorney, or adjuster in order to process any claim for reimbursement of charges incurred. SIGNATURE: PRINTED NAME: DATE: 7 @2017 Carmel Wellness Center Inc. All Rights Reserved

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