Personal Injury Questionnaire

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1 Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer to be called? Address City State Zip Patient SSN# Sex Male Female Do you? Rent Own Language (If other than English) Ethnicity (Mark one) Hispanic or Latino Not Hispanic or Latino Race (Mark one or more) American Indian or Alaska Native Asian White Black or African American Native Hawaiian or Other Pacific Islander Cell Phone Cell Phone Carrier Home Phone Occupation Employer/ School Employer/ School Address _ City State Zip Employer/ School Phone If Minor, Parent/Legal Guardian s Name Married Single Widowed Divorced Separated Minor Partnered for years Other Spouse s Name Spouse s Cell Phone Spouse s Employer How did you hear about us? Insurance Company Policy # Group # Relationship to the patient Self Spouse Child Other * If you selected self please stop here and proceed to the next section. Policy Holder First M Last Policy Holder s Date of Birth Sex Male Female Policy Holder s Address, City, State, Zip Policy Holder s Employer Employer City State Zip Employer Phone Secondary Health Insurance Insurance Company Policy # Group # Relationship to the patient Self Spouse Child Other * If you selected self please stop here and proceed to the next section. Policy Holder First M Last Policy Holder s Date of Birth Sex Male Female Policy Holder s Address, City, State, Zip Policy Holder s Employer Employer City State Zip Employer Phone Place of Accident Insurance Information (for office use only) Business Name Address City State Zip Phone Fax Case # Accident # Contact Phone Additional Information Insurance Company Address City State Zip Phone Fax Case # Authorization # Claim Adjuster Phone Additional Information Accident Information Please give a detailed description of how this accident occurred. 1 of 2

2 Details Regarding the Accident Date of Accident Time of Accident am/pm Did you report the accident? Yes No Did they file an accident report? Yes No *If yes, please provide a copy of the accident report. Were you admitted to the emergency room? Yes No Hospital Name Have you been able to work since the injury? Yes No Were you knocked unconscious? Yes No Other doctors seen for this accident Address Explain treatment Address Have you retained an attorney? Yes No Treating Doctor Explain treatment Were any x-rays taken for this accident? Yes No Firm Name Attorney Name Contact Address City State Zip Phone Fax Emergency Contact This must be someone NOT living in your household. Name: Relationship: Cell Phone: Home Phone: Address: City, State, Zip: Designation of Personal Representative Name: Relationship: Cell Phone: Home Phone: Address: City, State, Zip: I hereby designate the above named individual as my personal representative who may act on my behalf for the purpose of: Consenting to use and disclosure of my health information, authorizing use and disclosure of my health information, and receiving information that otherwise would be sent me. If I am incapacitated, my personal representative may also sign any form (such as authorization, revocation of authorization, request for access to information and/or billing inquiries), the uses of which are described in privacy policies and procedures. I understand that a person who is identified in my medical record as having medical power of attorney or other legal authority to act on my behalf is additionally recognized as my personal representative. I understand that I have the right to revoke this authorization at any time. Revoking this authorization must be made in writing, signed, and dated. Authorization and Medical Release I affirm that the above information is correct to the best of my knowledge and it is my responsibility to inform this office of any changes in my medical status. I authorize the doctor to treat my condition as he deems appropriate and to grant full disclosure for all previous or concurrent care. I agree to grant full indemnity to Alternative Wellness & Chiropractic Center and it s physicians for complications related to all pre-existing conditions medically diagnosed or otherwise not disclosed. Patient or Guardian Signature Date Print Guardian Name Relationship to Patient 2 of 2

3 Name: I. HEALTH HISTORY Current Medication:* I will provide a list of my medications. Personal Disease/Illness List any past history of disease/illness Month/Year Hospitalizations/Surgeries/Injuries List Past Hospitalizations/Surgeries/Injuries Month/Year Allergies:* Medication Intolerance:* Family Disease/Illness List any family history of disease/illness Relationship Month/Year Primary Physician(s) Date of Last Exam Date of Last X-ray Date of Last EKG Additional Tests Date Performed II. REVIEW OF SYSTEMS Have you at any time had: (Check all that apply) Head and Neck Digestive Decreased hearing Difficulty swallowing Ringing in ears Indigestion or heartburn Frequent ear infections Nausea/vomiting Dizzy spells Diarrhea Failing vision Constipation Double or blurred vision Blood in bowel movement Eye pain Black bowel movement Repeated eye infections Neurological/Physc Recurrent nose bleeds Numbness/Tingling Sinus/throat infections Headache Cardiovascular Nervousness High blood pressure* Memory Loss Pain (chest, arms or legs) Moodiness Palpitations Difficulty falling asleep Irregular heart beat Difficulty staying awake Swollen ankles Increased irritability Fainting spells Depression/Anxiety Endocrine Chronic fatigue Weight gain/weight Loss (recent) Bruise easily Cold extremities Tremors (shaking of hands) Convulsions Muscle weakness Respiratory Hoarseness Persistent cough Blood in spit Shortness of breath Skin Rash Hives Moles (cancerous) Genitourinary Diabetes* Painful urination Blood in urine Frequent urination Frequent night time urination Loss of control of urine Sexual dysfunction Musculoskeletal Neck pain Joint swelling Mid back pain Low back pain Foot pain Stiff joints Other Symptoms

4 Women Only Are you pregnant? Y N If Yes, Last Menstrual Period Due Date Are you nursing? Y N Are you planning a pregnancy? Y N Do you experience any of the following? (Check all that apply) Breast tenderness associated with cycle Breast fibroids, benign masses Menstruation Problems Uterine fibroids Endometriosis Vaginal discharge, dryness, itchiness Thyroid Problems Hot flashes Night sweats (in menopausal females) Urinary Tract, bladder, kidney infections Other Men Only Do you experience any of the following? (Check all that apply) Prostate problems Difficulty with urination, dribbling Difficult to start and stop urine stream Pain or burning with urination Interruption of stream during urination Pain on inside of thighs, legs or heels Feeling of incomplete bowel evacuation Decreased sexual function Other _ III. LIFESTYLE & WELLNESS (Check all that apply) In general, I believe my health to be: Excellent Very Good Good Fair Poor How many glasses of water do you drink a day? Less than 1 1 to 2 More than 2 Do you drink caffeinated or energy beverages? Y N Do you drink alcohol? Y N Social Quit Do you smoke?* Y N Social Quit Do you eat 3 meals per day? Y N Sometimes Do you exercise? Y N Seasonally Do you have trouble? Falling Asleep Staying Asleep IV. PRESENT SYMPTOMS Rate your pain 0 to 10, ten being the worst Neck Pain Mark ALL areas of pain on figures below Mid Back Pain Low Back, Hip Pain Right Left Left Right Other Pain V. CERTIFICATION I certify that I have read and understand the above information. I acknowledge that I have answered the above questions correctly and to the best of my ability. I will not hold my chiropractor or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. Patient/Guardian Signature Date (Office Use Only) The above health history questionnaire was reviewed by (Physician) Date

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