20. Please describe any pain or symptoms: a. DURING the accident: b. IMMEDIATELY AFTER the accident: c. LATER THAT DAY: d.
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1 Name Date of Birth Phone Address City State Zip Employer s Name Employer s Address Your Ins. Co. Claim # Claims Adjustors Name Driver/Owner Have you retained an attorney? ( ) Yes ( ) No If yes attorney s name Were there any witnesses? ( ) Yes ( ) No, If yes, please provide name(s) and contact info. Nature of Accident: 1. Date of Accident: Time of Day Weather Conditions 2. Were you: ( ) Driver ( ) Front Seat Passenger Passenger Back Seat: ( ) Left ( ) Middle or ( ) Right 3. Number of people in your vehicle? Make/Model of vehicle? 4. Number of people in other Vehicle(s)? Make/Model of vehicle(s)? 5. What direction were you headed? ( ) North ( ) East ( ) South ( ) West on name of street 6. What direction was the other vehicle headed? ( ) North ( ) East ( ) South ( ) West on name of street 7. Were you stopped or still moving at the time of the accident? 8. Were you struck from: ( ) Behind ( ) Front ( ) Left side ( ) Right side 9. What part of your car was hit? 10. Were any vehicles in the accident totaled? ( ) Yes ( ) No. If yes, which vehicle(s) was totaled? 11. Were you pushing on the brake pedal when the accident occurred? ( ) Yes ( ) No 12. Were you wearing a seat belt? ( ) Yes ( ) No. If yes were you wearing a Lap Belt ( ) Yes ( ) No and/or a Shoulder Belt ( ) Yes ( ) No ( ) 13. What height was your headrest set at? top of headrest comes to: ( ) top of neck ( ) middle of head or ( ) top of head 14. Did you see the accident coming? ( ) Yes ( ) No, If yes, did you brace for the accident? ( ) Yes ( ) No 15. What direction was your head turned during the accident? ( ) Forward ( ) Left ( ) Right ( ) Backwards 16. Did any part of your body hit anything within the car? 17. Were you knocked unconscious? ( ) Yes ( ) No. If yes, for how long? 18. Were police notified? ( ) Yes ( ) No, If yes, was a report completed? ( ) Yes ( ) No 19. In your own words, please describe the accident: 20. Please describe any pain or symptoms: a. DURING the accident: b. IMMEDIATELY AFTER the accident: c. LATER THAT DAY: d. THE NEXT DAY:
2 21. What are your PRESENT complaints and symptoms? 22. Did you go to the hospital after the accident? ( ) Yes ( ) No. If Yes Name 23. Have you ever been treated by another doctor since the accident? ( ) Yes ( ) No. If yes, please list doctor s name, address, and phone: 24. What type of treatment did you receive? 25. Since this injury occurred, are your symptoms: ( ) Improving ( ) Getting Worse ( ) Same 26. CHECK SYMPTOMS YOU HAVE NOTICED SINCE ACCIDENT: Headache Irritability Numbness in Toes Face Flushed Feet Cold Neck Pain Chest Pain Shortness of Breath Buzzing in Ears Hands Cold Neck Stiff Dizziness Fatigue Nervousness Lights Bother Eyes Head seems Too Heavy Loss of Balance Stomach Upset Sleeping Problems Depression Fainting Constipation Back Pain Loss of Smell Pins & Needles in Arms Pins & Needles in Legs Loss of Memory Loss of Taste Fever Tension Numbness in Fingers Ears Ring Diarrhea Cold Sweats Symptoms Other Than Above 27. Have you lost time from work as a result of this accident? ( ) Yes ( ) No. If yes, please complete this question. a. Last Day Worked: b. Type of Employment: c. Are you being compensated for time lost from work? ( ) Yes ( ) No. If yes, please state type of compensation you are receiving? 28. Do you notice any activity restrictions as a result of this injury?( ) Yes ( ) No. If yes, please describe, in detail: 29. Did you have symptoms similar to your current injuries BEFORE THIS ACCIDENT? ( )Yes ( ) No, If yes, please describe in detail: 30. Have you ever been treated for a work injury, personal injury, or car accident before? ( ) Yes ( ) No. If yes, please describe, including date(s) and type(s) of accident(s) and injuries that occurred. Patient Signature: Date:
3 MARK ALL AREA(S) OF PAIN OR UNUSUAL FEELING WITH THE FOLLOWING SYMBOLS ON THE DIAGRAM BELOW Numb Tingling Burning Cramping/Spasms Stabbing/Sharp Achy/Dull NNNN TTTTT BBBB CCCCCC SSSSSSSS AAAA Right Left Left Right Please mark on the pain scale from 0 to 10 the pain you feel with this condition. Patient Signature: Date:
4 Informed Consent I hereby request, authorize and consent: West Portland Chiropractic 322 NW 5th Avenue, Suite 305 Portland, OR to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic X-rays, on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future work at the clinic or office listed below or any other office or clinic. I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there is a very small risk of serious injury due to treatment (most research shows a risks of 1 in 1,000,000 to 1 in 3,000,000 chance of serious injury), including but not limited to fractures, disc injuries, and stroke. For comparison ibuprofen taken over a long period of time increases the risk of a stroke by almost three times. I do not expect the doctor to be able to anticipate and explain all risks and complications. Therefore, I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below, I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Print Patient name Patient Signature or Parent/Guardian Signature if younger than 18 Print name of Parent or Guardian Your Relationship to Patient Date
5 Patient Privacy Agreement Verification We are very concerned with protecting your privacy, especially in matters that concern your personal health information. In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to supply you with a copy of our privacy policies and procedures that you will receive at your first appointment. We encourage you to read this document carefully, for it outlines the use and limitations of the disclosure of your health information and your rights as a patient. If you ever have any questions or concerns regarding the use or dissemination of your personal health information, we would be happy to address them. I acknowledge that I have received a copy of Notice of Privacy Practices for Protected Health Information for this office Patient name Patient Signature or Parent/Guardian Signature if younger than 18 Printed name of Parent or Guardian Your Relationship to Patient Date
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Full Name: Gender M F Age: Birth Date: / / Social Security#: - - Driver s License #: Home Phone: ( ) Employer: Occupation: Work Phone: ( )
Personal Injury / Accident Medical History Intake Form Release Chiropractic and Wellness Center Please provide your Driver s License to our staff for your file. ABOUT YOU Full Name: Gender M F Age: Birth
MALINA CHIROPRACTIC 3826 N. Druid Hills Rd Decatur Georgia 30033 Office 404-352-3609 Fax 404-325-8859
MALINA CHIROPRACTIC 3826 N. Druid Hills Rd Decatur Georgia 30033 Office 404-352-3609 Fax 404-325-8859 Car Accident Questionnaire Name: Age: Date of birth: Date: LAST FIRST MIDDLE Address: Social Security
Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address
PLEASE PRINT CLEARLY : NEW PATIENT FORM Name Last) (First) ( (M.I.) Birth Social Security Age Sex: M / F Home Address City State Zip Complaint/ Area to be treated Email Address Home Phone ( ) Drivers Lic
JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557
FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:
CAMARILLO AQUATICS AND REHABILITATION SERVICES
CAMARILLO AQUATICS AND REHABILITATION SERVICES Last Name First M.I. Address Apt.# City State Zip Code Phone # SS# Date of Birth Sex M F Driver s License # Marital Status: S M D W Spouse s Name How did
ACCIDENT CHIROPRACTORS Main Office: 3326 N. 7 th Street, Phoenix, AZ. 85014 Telephone: (602) 253-8888 Facsimile: (602) 252-0845
PATIENT HISTORY & REGISTRATION FORM Name: Age: Date of Birth: Date: LAST FIRST MIDDLE Address: Social Security #: City, State, Zip: Marital Status: M S W D Home Phone: ( ) Work Phone: ( ) Employer: Spouse
Orthopedic Initial Questionnaire
Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:
Name: Mailing Address: First M.I. Last Today s Date: Physical Address: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: Employer: Occupation: Employer s Address: Work
Premier Healthcare of Placerville
Premier Healthcare of Placerville 1980 Broadway, Placerville, CA 95667 (530) 622-3536 Fax (530) 622-3538 WORKERS COMPENSATION INJURY QUESTIONNAIRE Name: Social Security#: of Birth: Today s : To insure
ACE PHYSICAL THERAPY & SPORTS MEDICINE INSTITUTE PATIENT REGISTRATION
ACE PHYSICAL THERAPY & SPORTS MEDICINE INSTITUTE PATIENT REGISTRATION ALEXANDRIA FAIRFAX FALLS CHURCH LEESBURG HERNDON TYSONS CORNER PATIENT INFORMATION (Please Print Clearly) Name Last First Middle of
Home Phone Work Cell Email
Dr. Jerrid Goebel Licensed Acupuncturist 824 1 st Street Dr. Stuart Johnson Sturgis, South Dakota, 57785 Dr. Al Gunderson Telephone (605) 347-4003 Todays date: Patient s Name Date of Birth age Address
Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Last Name First Name Middle Initial Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Home Phone ( ) Mobile
DEL MAR PHYSICAL THERAPY Patient Information
PLEASE PRINT CLEARLY DEL MAR PHYSICAL THERAPY Patient Information Name Birthdate Last First M.I. MM/DD/YYYY Age Sex M / F Marital Status SS# Address City Zip Phone ( ) Work ( ) Cell ( ) Email **********************************************************************************
MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: M F 6) Date of Birth (DOB): / / 7) Marital