Accident Claim Number - You Have Been Laid, Now What?
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1 Personal Injury Information First Name: / / Address: City/Town: Last Name: Phone: State: Zip Code: Your Auto Ins. Co Phone: Address: Accident Claim #: Agent s Name: Driver/Other Vehicle: Ins. Co: Policy #: Have you retained an attorney? Name: Were there any witnesses? Name/s: Nature of Accident 1. Date of Accident: Time of Day: Road Conditions: 2. Were you: Driver Passanger Front Seat Back seat 3. Number of people in your vehicle: In the other vehicle: 4. What direction were you headed? rth East South West 5. On (name of street): 6. What direction was the other vehicle headed? rth East South West 7. On (name of street): 8. Were you struck from: Behind Front Left Side Right Side 9. Were you knocked unconscious? If yes, for how long? 10. Were the police notified? 11. In your own words, please describe the accident: 12. Did you have any physical complaints BEFORE THE ACCIDENT? If yes, please describe in detail: 1 Back In Balance Redmond nd Ave NE Redmond, WA Phone - (425) Fax (425)
2 13. Do you have any congenital (from birth) factors which relate to this problem? If yes, please describe: 14. Do you have any previous illnesses that relate to this case? If yes, please describe: 15. Please describe how you felt: During the accident: Immediately after the accident: Later that day: The next day: 16. What are your present complaints and symptoms? 17. Where were you taken after the accident? 18. Have you been treated by another doctor since the accident? If yes, please list the doctor s name and address: 19. What type of treatment did you receive? 20. Do you notice any activity restrictions as a result of this injury? If yes, please describe in detail: 21. Since this injury occurred, are your symptoms: Improving Getting worse Same 22. Have you lost time from work as a result of this accident? If yes, please complete the following question: Last date worked: Dates you missed work: Type of employment: 23. Are you being compensated for time lost from work? If yes, please state type of compensation you are receiving: 24. Have you ever been involved in an accident before? If yes, please describe, including date(s) and type(s) of accidents as well as injury(ies) received: 25. Where were you taken after the accident(s)? 26. Have you been treated by another doctor since the accident(s)? If yes, please list the doctor s name: 27. What type of treatment(s) did you receive? (Patient Signature) (Date) 2 Back In Balance Redmond nd Ave NE Redmond, WA Phone - (425) Fax (425)
3 BEFORE ACCIDENT Pain Drawing Attending Dr.: Using the letters below, mark the areas on your body where you feel the described sensations. Include all affected areas. Please complete the picture by drawing your face. A = Ache B = Burning N = Numbness P = Pins & Needles S = Stabbing Patient Signature: SUBJECTIVE and OBJECTIVE NUMERICAL OUTCOME MEASURE ASSESSMENT 3 Back In Balance Redmond nd Ave NE Redmond, WA Phone - (425) Fax (425)
4 BEFORE ACCIDENT Visual Analog Scale Please indicate your level of pain on the scale below (Please circle and label a number for each symptom/body part that is causing pain/discomfort/or problems) pain Unbearable pain Activities of Daily Living People with vertebral subluxation may find that certain activities are restricted or difficult to do. Circle the numbers that correlate to the activities that you find difficult to do because of your condition: 1. Sleep through the night 2. Get out of bed easily 3. Make your bed 4. Bathe yourself 5. Wash, comb or dry hair 6. Wash dishes for more than 10 minutes 7. Go to the bathroom 8. Put socks, shoes or clothing on/take them off 9. Walk up flights of stairs 10. Walk down flights of stairs 11. Turn a doorknob 12. Open a heavy door 13. Sit in a chair for minutes before discomfort 14. Sit in a chair for minutes before the need to stretch 15. Get up from a low seat 16. Cross legs for minutes 17. Walk for minutes 18. Stand for minutes 19. Exercise for minutes 20. Travel on a journey that takes over hours 21. Push/pull vacuum cleaner or mower 22. Carry items like groceries/child or boxes, etc. 23. Wash the floors, kitchen or bathroom 24. Shovel snow or dirt 25. Bend over to garden 26. Use hand held tools (pencil, hammer, screwdriver, etc.) 27. Reach in front or overhead to perform a task 28. Enjoy hobbies or social activities 29. Sit at a desk/use computer for minutes 30. Hold Book/Tablet/Phone for minutes Circle any of the following conditions you are currently experiencing or are suffering from: 1. Neck or back weakness 2. Restricted movement of neck or back 3. Persistent tender areas in muscles of neck or back 4. Catch or kink in neck or back Signature: Office Use Only Total # ADL items circled: Subjective total: 4 Back In Balance Redmond nd Ave NE Redmond, WA Phone - (425) Fax (425)
5 AFTER ACCIDENT Pain Drawing Attending Dr.: Using the letters below, mark the areas on your body where you feel the described sensations. Include all affected areas. Please complete the picture by drawing your face. A = Ache B = Burning N = Numbness P = Pins & Needles S = Stabbing Patient Signature: SUBJECTIVE and OBJECTIVE NUMERICAL OUTCOME MEASURE ASSESSMENT 5 Back In Balance Redmond nd Ave NE Redmond, WA Phone - (425) Fax (425)
6 AFTER ACCIDENT Visual Analog Scale Please indicate your level of pain on the scale below (Please circle and label a number for each symptom/body part that is causing pain/discomfort/or problems) pain Unbearable pain Activities of Daily Living People with vertebral subluxation may find that certain activities are restricted or difficult to do. Circle the numbers that correlate to the activities that you find difficult to do because of your condition: 1. Sleep through the night 2. Get out of bed easily 3. Make your bed 4. Bathe yourself 5. Wash, comb or dry hair 6. Wash dishes for more than 10 minutes 7. Go to the bathroom 8. Put socks, shoes or clothing on/take them off 9. Walk up flights of stairs 10. Walk down flights of stairs 11. Turn a doorknob 12. Open a heavy door 13. Sit in a chair for minutes before discomfort 14. Sit in a chair for minutes before the need to stretch 15. Get up from a low seat 16. Cross legs for minutes 17. Walk for minutes 18. Stand for minutes 19. Exercise for minutes 20. Travel on a journey that takes over hours 21. Push/pull vacuum cleaner or mower 22. Carry items like groceries/child or boxes, etc. 23. Wash the floors, kitchen or bathroom 24. Shovel snow or dirt 25. Bend over to garden 26. Use hand held tools (pencil, hammer, screwdriver, etc.) 27. Reach in front or overhead to perform a task 28. Enjoy hobbies or social activities 29. Sit at a desk/use computer for minutes 30. Hold Book/Tablet/Phone for minutes Circle any of the following conditions you are currently experiencing or are suffering from: 1. Neck or back weakness 2. Restricted movement of neck or back 3. Persistent tender areas in muscles of neck or back 4. Catch or kink in neck or back Signature: Office Use Only Total # ADL items circled: Subjective total: 6 Back In Balance Redmond nd Ave NE Redmond, WA Phone - (425) Fax (425)
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