INITIAL DOCTOR-NEW PATIENT INTERVIEW FORM

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INITIAL DOCTOR-NEW PATIENT INTERVIEW FORM Patient: Age: Birth Date: Time In: Time Out: Date of Accident: Height Weight Date Of Exam: Sex: M F Marital Status: Spouse Name: # of Children: Occupation: Years: Employer: Are you or have you missed time from work? Yes No Type of Work: Office Clerical Light Moderate Heavy Labor Describe the type of work performed: Were you on-the-job when the accident occurred? Were you the: Driver Front Seat Passenger Rear Seat Passenger Other Vehicle was driven by: Did your vehicle strike another vehicle? Did another vehicle strike your vehicle? Were you struck from: Behind Front Driver s side Passenger s side other Were traffic citations issued? (Anyone given a ticket?) To whom? You Driver of your vehicle Driver of other vehicle None Were police at the scene? If yes, was a report made? Did accident occur on public or private property Where did the crash occur? (Street/highway) Your Vehicle (Year, Make, Model): Your speed at the moment of accident: Full Stop Slowing Accelerating Legal Limit The other Vehicle (Year, Make, Model) Time of day: Daylight Dawn Dusk Dark Road conditions: Dry Damp Wet Snow Ice Other Head restraints: None Integral Type Adjustable: Up Down Don t know If adjustable, was the position altered by the accident? Was the seat back adjustment altered by the accident? (did the seat back break) Seat Belt: Shoulder & Lap Belt Lap Belt only None worn Did air bag deploy? If Yes, were you struck by airbag? Were you burned? Body position: Head position: Forward Left Right Up Down Position of Hands: One on steering wheel Two on steering wheel N/A Were brakes applied at impact? Copyright AIPIP All rights reserved 1

Patient: Page 2 Accident Description: (How did the accident happen?) Were you aware of impending crash?: Did your body hit any part of your vehicle? If yes, describe Did anything inside the vehicle strike you? If yes, describe Did your vehicle hit any other object after the crash? If yes, describe Were you wearing a hat or eye or sunglasses? Yes No If yes, were they still on after crash? Did you lose consciousness? If yes, for how long Estimated damage to your vehicle: None Minimal Moderate Major Estimated damage to other vehicle: None Minimal Moderate Major Since the crash, tell me ALL symptoms or injuries you have experienced and specifically when each began: Where did you go after accident? Hospital Urgent Care Family Provider Home Work Other Emergency Room Treatment: Were you seen in the ER: Which hospital: Were taken by ambulance? Date seen if not taken by ambulance Was treatment given? If yes, X-rays: Yes If yes, which body parts x-rayed Results of X-rays: Lab work Results: Cervical collar Yes No Ice Medication: If yes, name of Rx: Other treatment: Follow-up Instructions: None Work restriction If yes, describe Other Treatment Since Crash : Doctor: Specialty: Date first seen: Referred by: Treatment type: Treatment frequency: Treatment duration: Currently treating? Work restriction If yes, describe Special tests: Referred to: Did treatment help? Comments: Copyright AIPIP All rights reserved 2

Patient: Page 3 How long before you felt symptoms from the crash? Immediately hour(s) day(s) week(s) Some symptoms felt immediately, others came on later Any pains or symptoms PRIOR to the crash? PRIOR TO the crash, did you have any trouble with: Headaches Neck pain Mid back pain Low back pain Besides you, how many others were in the vehicle? # Past History: Serious illness? (cancer, diabetes, asthma, etc) No Yes Have you ever been in any other car crashes? No Yes If yes, did you get hurt? No Yes Chief Complaint 1 Chief Complaint 2 Chief Complaint 3 Chief Complaint 4 Chief Complaint 5 Chief Complaint 6 Treatment by Another Chiropractor: Dates: Copyright AIPIP All rights reserved 3

Patient: Page 4 Previous Injuries, Hospitalizations, Surgeries, Fractures, Workman s Comp Injuries Have you ever been Hospitalized? Have you ever broken any bones? Ever been hurt at work and then had to see a doctor because of it? (Workman s Comp claim) Any previous injuries to the areas that hurt now? (ex: prior history of back pain, neck pain, headache) Have you ever had surgery? What was done Family History: #1.Father, #2.Mother, #3.Sister (A, B, Etc), #4.Brother (A, B, Etc.) Cancer Diabetes Heart Disease CVA HBP Epilepsy TB Other Other Other Other Other Psycho-Social History: Changes to Activities of Daily Living Since the Accident: Recreational/Exercise: Type: Freq. /Wk; Duration Min. / Hrs: Social Habits (Please Circle Appropriate Responses and Fill In The Blanks) Tobacco: Are you a smoker? If yes: /packs per day for years Alcohol Glasses Of Wine, Beer, Mixed Drink/ Day, Wk, Mo.; Has your Sleep been Interrupted since the crash? If yes: Before the crash I slept hours per night. Now I only sleep hours per night. Do you have Anxiety now? Are you anxious or fearful when riding in a car now? Dr. initials: Copyright AIPIP All rights reserved 4

Patient: Page 5 Work Routine/Duties under Duress Able Restricted Unable Comments Sit in office chair 1 2 3 4 5 Stand erect 1 2 3 4 5 Climb steps / stairs 1 2 3 4 5 Stoop to retrieve 1 2 3 4 5 Crouch to retrieve 1 2 3 4 5 Kneel to retrieve 1 2 3 4 5 Reach overhead 1 2 3 4 5 Lift; waist to shoulder height 1 2 3 4 5 Carry object, 100 feet 1 2 3 4 5 Push 1 2 3 4 5 Pull 1 2 3 4 5 Balance 1 2 3 4 5 Crawl 1 2 3 4 5 Reach 1 2 3 4 5 Handle objects appropriately 1 2 3 4 5 Finger/Hand strength/coordination 1 2 3 4 5 REVIEW OF SYSTEMS: Please write all numbers that apply: #1. Presently have, #2. Previously had, #3. Related to crash GENERAL MUSCULOSKELETAL CARDIOVASCULAR Allergy Arthritis Hardening of arteries Chills Bursitis High blood pressure Convulsions Foot Trouble Low blood pressure Dizziness Hernia Pain over heart Fainting Low back pain Poor circulation Fatigue Lumbago Rapid heart beat Fever Neck pain/stiffness Slow heart beat Headache Shoulder blade pain Swelling of ankles Sleep loss Pain or numbness in: RESPIRATORY Weight loss Shoulders Chest pain Nervousness/depression Arms Chronic cough Neuralgia Elbows Difficult breathing Numbness Hands Spitting up blood Sweats Hips Spitting up phlegm Tremors Legs Wheezing EYES, EARS, NOSE, THROAT Knees GASTROINTESTINAL Asthma Feet Belching or gas Colds Painful tailbone Colitis Sore throat Poor posture Colon trouble Deafness Sciatica Constipation Dental decay Spinal curvature Diarrhea Earache/noises GENITO-URINARY Difficult digestion Ear discharge Bedwetting Distention of abdomen Sinus infection Blood in urine Excessive hunger Enlarged glands Frequent urination Gall bladder trouble Enlarged thyroid Inability to control bladder Hemorrhoids Nose bleeds Kidney infection or stones Intestinal worms Failing vision Painful urination Jaundice Far sighted Prostate trouble Liver trouble Gum trouble Pus in urine Nausea Hay fever Painful menstruation Pain over stomach Hoarseness Hot flashes Poor appetite Nasal obstruction Irregular cycle Vomiting Near sighted Lumps in breasts Vomiting blood Other: Dr. Signature: Date Copyright AIPIP All rights reserved 5

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