Potomac Valley Chiropractic Personal Injury

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1 Potomac Valley Chiropractic Personal Injury Spiro Theodore, D.C Darnestown Road, L8 Gaithersburg MD Please Complete all applicable fields Date: DEMOGRAPHICS Full Name: Date of Birth: Address: City State Zip Home Phone: Cell Phone: Work Phone (optional): Cell Phone Carrier (for text messages): Verizon AT&T Sprint T-Mobile Other: Contact Preference: Home Phone Cell Work Gender: Male Female Status: Married Divorced Single Widowed Separated Emergency Contact (Name/Number/Relation): Occupation: Primary Language: English Spanish Other: Race: Native Hawaiian/Other Pacific Islander Asian Latino or Hispanic White Black/African American Other: Decline to State Primary Care Physician Name and Phone #: INSURANCE Have you called your insurance to obtain medical information? Yes No Please Note: We DO NOT accept third party payments, unless a written agreement to pay Potomac Valley Chiropractic is provided prior to treatment. Who is responsible for the bill? Self Health Ins Auto Ins Attorney Other: Insurance Company: ID/Claim#: Policy Holder Name: Policy Holder Relationship to Patient: Self Spouse Parent Other: Auto-Adjuster Name and Number: Billing Address for Claims: 1 5

2 Accident Details Date of the accident Time of accident: AM or PM State where accident occurred? City Street/Intersection Vehicle Make and Model 1. How many vehicles were involved in the accident? 2. What direction were you traveling in? 3. What type of impact was the auto accident? Rear End T-Bone Front Side 4. Did your vehicle hit anything after the accident? Yes No If YES, please describe 5. Where were you sitting in the vehicle during the accident? Passenger Driver Back Left Back Right 6. Did you know the accident was coming? Yes No 7. What type of vehicle impacted you? 8. At the time of the impact, how fast was your vehicle going? 9. At the time of the impact, how fast was the other vehicle moving? 10. During and after the crash what happened to your vehicle? (Circle all that apply) Kept going straight Spun around Kept going straight hitting a car in front Spun around and hit a stationary object Was hit by another vehicle Hit a stationary object 11. Did you lose consciousness during the accident? Yes No 12. Did you go to the hospital? Yes No Name of Hospital If No, Please skip Were you hospitalized overnight? Yes No How did you get there? What you were prescribed? Pain medication Muscle relaxers Neck brace 14. Did you receive any stitches for any cuts at the hospital? Yes No Were X-RAYS taken at the hospital? Yes No If yes, which area? 15. Was any other doctor consulted after your accident? Yes or NO, if so what was the doctor s name? What treatment was given? 16. Did your airbags deploy? Yes No 17. How was the visibility that day? Good Poor Wet Icy Foggy Other: 18. How was your head positioned during the accident? 19. How was our torso positioned during the accident? 20. How were your hands positioned during the accident? 21. Did your head hit anything during the accident? Yes No if YES, please describe 22. Where was the headrest positioned on your head? 23. Did you have your seatbelt on during the accident? Yes No 24. Choose the items the dented inward Floorboards Side door Dashboard 25. Choose the doors that would not open as a result of the accident Front left Front right Rear left Rear Right 26. Did any part of your body hit anything during the accident?( i.e. head hit steering wheel ) Yes No If Yes Please explain, 2 5

3 Potomac Valley Chiropractic Spiro Theodore, D.C Darnestown Road, L8 Gaithersburg MD MEDICAL HISTORY Height: Weight: MEDICATIONS: Please list any prescriptions, supplements or over the counter medications: Name of Medication: Prescribed By: Strength/Dose: Duration: (wks, months, yrs) I f more space needed, please use back of form ALLERGIES: Please list ALL allergies to medications, foods or environment: If more space needed, please use back of form Major Illness: Please list all past and current diagnosis (example Diabetes, Heart Disease, High Blood Pressure etc) Diagnosis: Date of Diagnosis: Doctor: Hospitalizations: Please list any hospitalizations (INCLUDING SURGERIES): 1. Reason for Hospitalization What Hospital? Outcome/Resolved?

4 FAMILY HISTORY: Please list any significant health problems that applies: Relationship: Medical History/Illness Deceased? Cause of Death? Mother: Father: Sister(s): Brother(s): Maternal Grandmother: Maternal Grandfather: Paternal Grandmother: Paternal Grandfather: SOCIAL HISTORY: Who do you live with? Alone Spouse With: Do you Smoke? Yes No Former Smoker Occasional Smoker Alcohol Use? None Causal Use Moderate Use Heavy Use Caffeine Use? None Less than 3 beverages 4 or more beverages Drug Use?: None Recreational User Addiction Exercise: Do you exercise? Never Daily Weekly How many times weekly? What Type(s) of exercise do you do? Have you ever had any sports related injuries? Yes No If yes, please describe: Is there anything else the doctor should know about your medical, social or family history? Potomac Valley Chiropractic never discloses your information to anyone selling or promoting products or services. HIPPA is strictly enforced. Please complete the following consents: OK to text appointment reminders, cancellations to your cell phone? Yes No Ok to leave voice messages on home and/or cell Yes No Cell only Home Only Ok to send to the address you provided? Yes No Is there anyone you consent to sharing information with about your appointments, treatment, insurance or financial issues (other than insurance companies or attorneys): 4 5

5 Potomac Valley Chiropractic Spiro Theodore, DC Darnestown Rd, L8 Gaithersburg MD Patient Name: Date: Please give a brief description of the problem(s) you are experiencing: Describe how this/these problems affects your daily activities such as walking, exercise, work or child care Problem Area #1: What date did the problem start: What caused the problem (if known): Is/are the problems getting better? Yes No Getting worse? Yes No Have you or are you seeing any other providers for these problems? Where is the problem the worst? Which side: Right Left Both Did the problem start: Suddenly Gradually Its Chronic How does it feel (circle all that apply): Achy Dull Stiff Sharp Throbbing Other: Rate your current pain level: (No pain) (Bad Pain) How does the pain feel at its best? (No pain) (Bad Pain) How does the pain feel at its worst? (No pain) (Bad Pain) Does the Pain travel or radiate? Yes No Is the Pain: Constant Frequent Occasional Intermittent Please color in or X the area (s) where you experience pain or discomfort Front Back Do you experience numbness? Yes No If Yes, where? Do you experience spasms? Yes No If Yes, where? Do you experience weakness? Yes No If yes, where? When is the pain worse? Morning Afternoon Night Gets worse as day goes on Stays the same What makes the pain worse? Sleeping Walking Standing Bending Driving Sitting Other: What makes the pain better? Rest Sleep Ice Heat Medication Sitting Massage Other: Do you have any history of: Low back pain: Yes No Neck Pain: Yes No Spinal or Neck Surgeries: Yes No If yes, please explain 5 5

6 Potomac Valley Chiropractic Spiro Theodore, DC Darnestown Rd, L8 Gaithersburg MD Problem Area #2: What date did the problem start: What caused the problem (if known): Is/are the problems getting better? Yes No Getting worse? Yes No Have you or are you seeing any other providers for these problems? Where is the problem the worst? Which side: Right Left Both Did the problem start: Suddenly Gradually It s Chronic How does it feel (circle all that apply): Achy Dull Stiff Sharp Throbbing Other: Rate your current pain level: (No pain) (Bad Pain) How does the pain feel at its best? (No pain) (Bad Pain) How does the pain feel at its best? (No pain) (Bad Pain) Does the Pain travel or radiate? Yes No Is the Pain: Constant Frequent Occasional Intermittent % 51-75% 26-50% 0-25% Please color in or X the area (s) where you experience pain or discomfort Front Back Do you experience numbness? Yes No If Yes, where? Do you experience spasms? Yes No If Yes, where? Do you experience weakness? Yes No If yes, where? When is the pain worse? Morning Afternoon Night Gets worse as day goes on Stays the same What makes the pain worse? Sleeping Walking Standing Bending Driving Sitting Other: What makes the pain better? Rest Sleep Ice Heat Medication Sitting Massage Other: Do you have any history of: Low back pain: Yes No Neck Pain: Yes No Spinal or Neck Surgeries: Yes No If yes, explain I have completed all this information to the best of my ability. I understand I am financially responsible for all services that are not covered by insurance, including co-pays and deductibles. Signature: Date: If under 18 years old, a parent or legal guardian must complete and sign forms. 6 5

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