PERSONAL INJURY QUESTIONNAIRE

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PERSONAL INJURY QUESTIONNAIRE Personal Information: Name: Home phone #: Address: Alt. phone #: City/State/Zip: Email address: Date of birth: Age: Social Security #: Insurance Information: (Vehicle You Were In) Name of Company: Phone #: Address: City/State/Zip: Name on Policy (if other than self): Policy #: Claim #: Accident Information: Date of accident: Time of Day AM/PM Were you ( ) Driver, ( ) Passenger, ( ) Front Seat, ( ) Back Seat. Were you wearing a seatbelt? ( ) Yes ( ) No Were you struck from ( ) Behind, ( ) Front, ( ) Left side, ( ) Right side? Were you headed ( ) North, ( ) South, ( ) East, ( ) West? Were the police notified? ( ) Yes ( ) No Do you have an attorney? ( ) Yes ( ) No If yes, please provide attorney contact info: Approximate speed of your vehicle: mph. Other vehicle? mph Where did the accident occur? In your own words, please describe the accident:

Current Medical Complaints: Prior to this accident, have you had any physical complaints similar to what you have now? ( ) Yes ( ) No If yes, please describe: Were you hospitalized after the accident? ( ) Yes ( ) No If yes, where? Were X-Rays taken ( ) Yes ( ) No Please read the following and check all that apply. Medical complaints since the accident: Neck pain Numbness in fingers Leg pain Low Back Pain Numbness in toes Arm/Shoulder pain Upper Back Pain Pins & Needles Legs/Feet Ears Ringing Mid Back Pain Pins & Needles Arms/Hands Headache Dizziness Loss of memory Fainting Sleep problems Loss of taste or smell Loss of balance Is pain worsened by any of the following: Sitting Walking Laying down Pulling Bending Lifting Standing Pushing Does your pain radiate (travel)? Is condition worse during certain times of the day? What aggravates your condition/pain? Is your pain getting progressively worse, better, or staying the same? Any home remedies? Is this condition interfering with Sleep? Routine? Other? Please describe any other symptoms you have that are not listed here:

Current Health Habits: Did/ do you Smoke/Use tobacco products? Y N Drink alcohol/take Drugs? Y N Diet (do you eat healthy foods?) Y N Drink water, how many glasses? Y N Exercise regularly? Y N Have teeth problems? Y N Have eye problems? Y N Have hearing problems? Y N Have sleeping problems? Y N Have occupational stress? Y N Have physical stress? Y N Have mental stress? Y N Have hobbies/sports injuries? Y N Sleeping posture: side stomach back What is your height? Weight? Have you been under medical and/or drug care? Do you have a primary care physician? Who? What medications are you taking? What side effects have you experienced from the medications and/or surgery? Do you take vitamins or supplements? Please all vitamins and/or supplements:

Past Health Conditions And/Or Symptoms: Headaches Muscular In coordination Prostate Problems Depression Neck Pain Visual Disturbances Abnormal Weight Light Bothers Eyes Upper Back Pain Dizziness Gain/Loss Loss of Memory Lower Back Pain Loss of Balance Loss of Appetite Ears Ring Shoulder Pain Nervousness Abdominal Pain Fever Irritability Elbow/Upper Arm Pain Ulcer Fainting Wrist pain High Blood Pressure Hepatitis Loss of taste Hand Pain Heart Attack Liver/Gall Bladder Diarrhea Chest Pains Hip/Upper Leg Pain Disorder Feet Cold Stroke Knee/Lower Leg Pain Cancer Hands Cold Ankle/Foot Pain Angina Tumor Stomach Upset Jaw Pain Kidney Stones Asthma Constipation Kidney Disorders Joint Swelling/Stiffness Pins & Needles in legs Loss of Balance Arthritis Bladder Infection Pins & Needles in arms Buzzing Painful Urination Rheumatoid Arthritis Numbness in fingers General Fatigue Loss of bladder control Numbness in Toe Family History: Fathers Side Mothers Side Heart Disease Arthritis Cancer Diabetes Other How old is, or was, your oldest living relative? years old As a result of my chiropractic care, I would like to: Please check all that apply Feel better quickly Have a healthier spine Have a healthier body by keeping my nervous system healthy Live a healthier lifestyle Signature Date

Terms of Acceptance When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understands both the objective and the method that will be able to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body s correction of vertebral subluxations. Our chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease of infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. I, have read and fully understand the above statements. (Print name) All questions regarding the doctor s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis. (Signature) (Date)

Emil A. Tocci, D.C. 2421 Long Beach Road Oceanside, NY 11572 (516) 766-1717 NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLWDGEMENT Patient Name: Date of Birth: I have received this practice s Notice of Private Practices written in plain language. The notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice s legal duties with respect to my information. I understand that this practice reserves the right to change the terms of its Notice of Private Practices, and to make changes regarding all protected health information resident at, or controlled by this practice. I understand I can obtain this practice s current Notice of Privacy Practices on request. Signature: Relationship to patient (if other that self): Date:

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