PERSONAL INJURY CASE HISTORY

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1 Name: Mowry Chiropractic Inc. 240 North Liberty Street, Powell, OH (614) (p) ~ (614) (f) PERSONAL INJURY CASE HISTORY 1. Circle the severity (0 = No Pain to 10 = Very Severe Pain) and Frequency of pain (% of the week you experience the pain). Condition / Problem Severity Frequency (% of week) Minimal Severe Occasional Constant a b c d e (Please mark the figures where you experience pain.) 2. Symptoms are worse in the (circle what applies) -morning -afternoon -night -Increase during the day -same all day -decrease during the day 3. Symptom (a.) is: Sharp / Dull / Burning / Aching / Throbbing / Numbness / Tingling / Pins & Needles 4. Symptom (b.) is: Sharp / Dull / Burning / Aching / Throbbing / Numbness / Tingling / Pins & Needles 5. Symptom (c.) is: Sharp / Dull / Burning / Aching / Throbbing / Numbness / Tingling / Pins & Needles 6. Symptom (d.) is: Sharp / Dull / Burning / Aching / Throbbing / Numbness / Tingling / Pins & Needles 7. Symptom (e.) is: Sharp / Dull / Burning / Aching / Throbbing / Numbness / Tingling / Pins & Needles 8. When did your symptoms begin (onset date)? 9. Do your symptoms radiate? 10. Has your condition? Improved Gotten Worse Stayed the same since it began 11. Circle the things that make your problems worse: Bending - Lying - Walking - Standing - Sitting - Movement - Twisting - Lifting - Sleeping 12. Is there anything you can do to relieve the problems? No Yes Describe: 13. Is this condition interfering with Work Sleep Daily Routine Recreation 14. Additional Comments: I certify that the above information is accurate to the best of my knowledge. Patient/Guardian Signature :

2 Mowry Chiropractic Inc Financial Policy Thank you for choosing Mowry Chiropractic Inc as your health care provider. We are committed to providing you with the best possible medical care. Please understand that payment of your bill is considered a part of your treatment. The following information is provided to avoid any misunderstanding or disagreement concerning payment for services provided by our office. Our office participates with a variety of insurance plans. It is your responsibility to: o Bring your current insurance card to every visit and notify us of any changes in coverage. o We will submit a claim to your insurance company for you. Balances not paid, per our contract by your primary insurance company may be billed to you. A statement will be sent to you or you may be notified of balances at our office. Ultimately you are responsible for payment of charges. o Be prepared to pay your co-pay at each visit. Payments may be made by cash, check or credit card. o I understand that my insurance carrier can choose to assign benefits to Mowry Chiropractic Inc or my insurance carrier may make payment directly to me. If payment is sent to me I am responsible to bring my explanation of benefits to Mowry Chiropractic and pay my bill in full. o I understand and certify that I am financially responsible for all healthcare service charges that are paid to me directly by my insurance carrier, as well as for any applicable co-payment, co-insurance, deductible or charges for non-covered services provided to me or any of my dependents. If you do not have insurance coverage or if a company with which we are not contracted insures you, payment in full is expected at time of service unless arrangements are made and kept. It is my responsibility to verify that I am in or out of network with Mowry Chiropractic. It is also my responsibility to know my chiropractic benefit information. Insurance benefits verified by Mowry Chiropractic are verified as a courtesy to me. They may not be an actual quote of benefits or payment. If you have questions about your insurance, we are happy to help you. Specific coverage issues, however should be directed to your insurance company member services department (number should be on your insurance card) This office charges for all services that are significant and separately identifiable. We bill for all procedures that are provided at Mowry Chiropractic Inc. If I am unable to pay my bill in full it is my responsibility to contact Mowry Chiropractic to set up a payment arrangements. Otherwise my balance maybe subject to Mowry Chiropractic s collection process.

3 All balances are due within 30 days of the statement due. Unpaid balances greater that 30 days are subject to our collection process. Accounts sent to our collection agency are subject to collection fees. Once an account has been turned over collections, payments and questions are to be made to the collection agency. There will be a fee charged for all massage appointments that are not kept and/or cancelled without 24-hour notice. There is a fee for all returned checks. There is an additional fee for all office visits scheduled after the posted hours. Emergency visits/walk-ins/non-scheduled appointments may also be charged an additional fee. There is a fee to copy all medical records including x-rays. If my treatment is result of an auto/personal injury accident and I am paid directly by the insurance company, I understand that is my responsibility to pay Mowry Chiropractic in full for services rendered to me. I understand that some of the codes submitted to my insurance company in conjunction with a manipulation may be coded as physical therapy. Also, any therapies performed at Mowry Chiropractic Inc may also take from my physical therapy benefit provided to me by my insurance carrier. Initials Thank you for understanding our financial policy. Please let us know if you have any questions or concerns. By signing below, I certify that I will pay Mowry Chiropractic Inc any co-payments, co-insurance, deductible or non-covered services. I will immediately pay Mowry Chiropractic Inc any payments I receive from my insurance company for services provided to my dependents or me. I will be responsible for any amounts not paid by insurance because I have not provided the appropriate insurance information for billing. Print Patient Name Signature of Patient or Guardian Witness

4 240 North Liberty Street Powell, OH (614) FAX: (614) Patient s Name: Address: City: ZIP: SS#: WELCOME TO OUR PRACTICE! How did you hear about us? (Please Check All That Apply) Internet/Search Engine Insurance Referral CONFIDENTIAL PATIENT INFORMATION Friend/Family Referral Walk-by/Drive-by Chief Complaint: Home Phone: Cell Phone: of Birth: Marital Status: M S W D Occupation: Employer: Address of Insured (if different from above): Are you present symptoms or condition related to, or the result of an auto collision, work-related injury or other personal injury? (Someone else might be responsible for payment?) Yes No Insurance Company: ID#: Name of Policy Holder: Ins. Phone Number: Group Number: Policy Holder s DOB: Policy Holder s Employer: Family Physician: (Note: May we send your health information to this provider Y / N Person to contact in case of emergency (Name and Phone): Have you ever been under Chiropractic Care? Y N If so, Who? Have you had any SPINAL X-Rays / MRI s / CT s taken in the last year? Y N If so, Where? What operations have you had? When? Serious Illness: When? Infectious Diseases: When? Do you have a pace maker? Y / N Have you ever had any Hip or Knee Replacements Y / N What medications or drugs are you taking? (check those that apply): Pain Killers Insulin Cholesterol Meds Blood Pressure Meds Muscle Relaxers Birth Control Other: What is your goal in our office? LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign at clinic s request, and convey directly to Mowry Chiropractic all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I hereby authorize the doctor to release any and all medical information to other healthcare providers involved in my care including but not limited to my primary care physician. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions. I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic's expenses. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement. Signature of Insured / Guardian

5 Mowry Chiropractic Inc. 240 North Liberty Street, Powell, OH (614) (p) ~ (614) (f) WORKERS COMPENSATION HISTORY Patient Name: Employers Name: Telephone Number: Address: City: State: Zip: Carrier Name: Telephone Number: Address: City: State: Zip: Have you retained legal counsel for this injury? Yes No If yes, give name and address: Injury Description present injury was received: Time of injury: A.M P.M. Overtime? Yes No Who saw the accident? Name Title Who reported the accident? Name Title How did the injury occur? If working on a machine, give description: Do you use foot or hand levers? Yes No Do you have to reach? Yes No Do you work overhead? Yes No Where? Movements on the job: Do you move to your: Right Left Up Down Under Over Do you pick up or lift? Yes No If yes, how much? How often? From where to where? Do you lift from: Ground Bench Platform Box Pallet Other: (Please Describe) Do you lift in and out of a machine? Yes No If working at a machine, do you? Sit Stand Kneel Is your work area cluttered? Yes No If yes, with what? Is your work area: Oily Dirty Slippery Other In your job do you push or pull? Yes No If yes, give specifics: Do you use a cart? Yes No Two-wheel Four-wheel Type of wheels: Rubber Steel Plastic Condition of cart: Good Bad Other Number of carts being pushed or pulled at once: Total amount of weight being pushed or pulled on a daily basis:

6 Office Work If your injury has occurred from office work only, please fill out the following: I : Sit at desk Walk Stand Stoop Hold Carry Other Give percentage, if applicable: Do you operate office machinery? Yes No If yes, what type? If your work is at a desk, give specifics of job, computer, typewriter, business machine, phone, etc. If walking, where to and job classification: Do you carry anything or pick anything up? Yes No If yes, what? Previous Work History Give a job description of services or work performed for each job classification or source of employment for the preceding 10 (ten) years Was a pre-employment exam performed or required? Yes No If so: : Doctor: Place: Have you ever applied for Workers Compensation benefits before? Yes No : Reason: Was there a time loss from work? Yes No From: To: Year: State the degree of recovery: Did you retain legal counsel for these injuries? Yes No If yes, give name and address: Present Work History What is the job classification of your normal job? Were you performing your normal job? Yes No What shift were you working? How long have you been at your present job? Has there been a time of loss or absenteeism caused from job injury? Yes No If yes, please explain: Average work week: Hours: Days:

7 Job Conditions Type of building: Type of floor: Rough Smooth Wood Concrete Steel Other: Type of windows: Open Closed No windows Type of ventilation in the building: Blower A/C Heat Exhaust None Other: Type of lighting in the building: Fluorescent Overhead On machine Other: Are you tired when you go home at night? Yes No Do you have any outside jobs? Yes No If yes, what type? Do you participate in any company-sponsored programs such as exercise, sports, etc? Yes No If yes, please describe: Type of shop: Union Non-Union Has outside help been hired? Yes No If yes, why? How many employees are in the plant? How many employees per shift? How many employees do your job? What is the current injury ratio for that job? How many employees have been injured doing your job? Do you like your job? Yes No If off work, do you want to return to your job? Yes No What changes would you make in your job? The above information is accurate and has been completed to the best of my knowledge: Patient Signature Staff Signature

8 Patient Name: Mowry Chiropractic Inc. 240 North Liberty Street, Powell, OH (614) (p) ~ (614) (f) T e r m s o f A c c e p t a n c e : The goal of our office is to enable patients to gain control of their health. To attain this we believe communication is the key. There are often topics that are hard to understand and we hope this document will clarify those issues for you. Please read the below and if you have any questions please feel free to ask one of our staff members. Informed Consent: A patient, in coming to the chiropractic doctor, gives the doctor permission and authority to care for the patient in accordance with the chiropractic tests, diagnosis, and analysis. The chiropractic adjustment or other clinical procedures are usually beneficial and seldom cause any problems. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible to injury. The doctor, of course, will not give any treatment or care if he/she is aware that such care may be contra-indicated. Again, it is the responsibility of the patient to make it known, or to learn through healthcare procedures what he/she is suffering from: latent pathological defects, illnesses or deformities which would otherwise not come to the attention of the chiropractic physician. The chiropractic doctor provides a specialized, non-duplicating health care service. Your doctor of chiropractic is licensed in a special practice and is available to work with other types of providers in your health care regimen. I understand that if I am accepted as a patient by a physician at Mowry Chiropractic, I am authorizing them to proceed with any treatment that they deem necessary. Furthermore, any risk involved, regarding chiropractic treatment, will be explained to me upon my request. Women Only: To the best of my knowledge I am / am NOT pregnant and (give my permission / don t give permission) to x-ray me for diagnostic interpretation. (Circle one above) (Circle one above) Missed Appointments: There is a possible fee charged for all appointments that are not canceled prior to scheduled visit. Any massage appointment that is not canceled 24 hours prior to scheduled appointment will be charged $35 - $70 Consent to Evaluate and Treat a Minor: I, being the parent or legal guardian of, have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care. Communications: In the event that we would need to communicate your healthcare information, to whom may we do so? Spouse: Children: Others: No one: May we leave messages regarding your personal healthcare information on any answering device, i.e. home answering machines or voic s? Yes [ ] No [ ] Acknowledgement I have read and fully understand the above statements. I have reviewed the notice of privacy practices (HIPAA) and have been provided an opportunity to discuss my right to privacy. Upon request I will be given a copy. Print Name: Signature: :

9 Functional Rating Index For use with Neck and/or Back Problems only. In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities. For each item below, please circle the number which most closely describes your condition right now. 1. Pain Intensity No Mild Moderate Severe Worst pain pain pain pain possible 2. Sleeping pain Perfect Mildly Moderately Greatly Totally sleep disturbed disturbed disturbed disturbed sleep sleep sleep sleep 3. Personal Care (washing, dressing, etc.) No Mild Moderate Moderate Severe pain; pain; pain; need pain; need pain; need no no to go slowly some 100% restrictions restrictions assistance assistance 4. Travel (driving, etc.) No Mild Moderate Moderate Severe pain on pain on pain on pain on pain on long trips long trips long trips short trips short trips 5. Work Can do Can do Can do Can do Cannot usual work usual work; 50% of 25% of work plus unlimited no extra usual usual extra work work work work 6. Recreation Can do Can do Can do Can do Cannot all most some a few do any activities activities activities activities activities 7. Frequency of pain No Occasional Intermittent Frequent Constant pain pain; pain; pain; pain; 25% 50% 75% 100% 8. Lifting of the day of the day of the day of the day 9. Walking No Increased Increased Increased Increased pain with pain with pain with pain with pain with heavy heavy moderate light any weight weight weight weight weight No pain; Increased Increased Increased Increased any pain after pain after pain after pain with distance 1 mile 1/2 mile 1/4 mile all walking 10. Standing No pain Increased Increased Increased Increased after pain pain pain pain with several after several after after any hours hours 1 hour 1/2 hour standing Name PRINTED ID#/SS# Plan ID Total Score Signature Institute of Evidence-Based Chiropractic

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