AUTOMOBILE ACCIDENT HISTORY FORM

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1 AUTOMOBILE ACCIDENT HISTORY FORM Today s Date File#: Your Name Date Of Accident Time Of Accident am/pm City Of Accident Street Of Accident Road Conditions At The Time Of Accident: Wet Dry Ice Other: Did the police come to the accident scene? Yes No Was there a report? Yes No Did you go to the hospital? Yes No If yes, what is the name of the hospital? How did you get to the hospital? What parts of your body were x-rayed at the hospital? What did the hospital do for your injuries? How long did you stay at the hospital? What bleeding cuts did you sustain during this accident? What bruises did you sustain during this accident? Where were you seated in the vehicle? Were you aware of the approaching collision prior to impact? Yes No Did you lose consciousness (black out) upon impact? Yes No How long? Did you experience a flash of light or explosion in your head? Yes No Did you experience any of these due to the accident? (Please circle) Confused; Disoriented; Light Headed; Dizzy; Nauseated; Blurred Vision; Ring/Buzz in Ears Are you currently suffering from any of the following (please circle)? Restlessness; Irritable; Difficult Concentrating; Difficult with Memory; Sleeplessness; Forgetfulness; Reduced Tolerance to Heat; Reduced Tolerance to Alcohol How far is the top of the headrest or seatback from the top of your head (approximately)? Inches above/below Are you currently working? Yes No Off work on: Returned to work on: Please describe, to the best of your knowledge, what happened during the accident:

2 File#: Patient Vehicle: List the year, make and model of the vehicle you were in: Year Make Model Was the car stopped at the time of impact? If yes, was the driver s foot also on the brake? If no, then estimate the speed of the vehicle you were in: mph If your vehicle was moving at the time of impact, was it: Slowing down? Gaining speed? Traveling at a steady speed? Yes No On what part of the automobile did your following body parts hit? Head hit Chest hit Rt/Lt Shoulder hit Rt/Lt arm hit Rt/Lt Hip hit Rt/Lt Leg hit Rt/Lt Knee hit Other: Which of the following vehicle parts broke during the accident? (please circle) Windshield Front Seat Back Right/Left Side Window Steering Wheel Other: Was the trunk of your body pointed straight forward at the time of the collision? Yes No If no, how was it turned? Was your head pointed straightforward? Yes No If no, what direction was it turned and by how much? Were you wearing a seatbelt? Yes No If yes, was it a lap seatbelt or shoulder-lap seatbelt? (circle one) Did you receive any injury or bruise from the seatbelt? Yes No If yes, then describe: What is the estimated cost of damage to the vehicle you were in? $ Insurance Company: Policy: Claim#: Conact person: Phone#: Other vehicle List the year, make and model of the other vehicle: Year Make Model Was the other vehicle moving at the time of the collision? Yes No If yes, what was its approximate speed? mph If the other vehicle was moving at the time of collision, was it (please circle): Slowing Down Gaining Speed Traveling at a Steady Speed Insurance Company: Policy: Claim#: Conact person: Phone#: Signature: Date:

3 Name: SHEPPARD CHIROPRACTIC Dr. Joseph A. Sheppard 3878 McMann Rd., Cincinnati, OH (513) (p) ~ (513) (f) CASE HISTORY File#: Circle the severity (0 = No Pain to 10 = Very Severe Pain) and Frequency of pain (% of the Day you experience the pain) Condition / Problem Severity Frequency (% of Day) Minimal Severe Occasional Constant (Please mark the figures where you experience pain.) 8. Symptoms are worse in the (circle what applies) -morning -afternoon -night -Increase during the day -same all day -decrease during the day 9. When did your symptoms begin (onset date)? 10. How did your symptoms begin? 11. Have you experienced these before? 12. Do your symptoms travel down your Legs / Arms? 13. Has your condition? Improved Gotten Worse Stayed the same since it began 14. Circle the things that make your problems worse: Bending - Lying - Walking - Standing - Sitting - Movement - Twisting - Lifting - Sleeping - Turning - Limited to

4 Name: File#: 15. Is there anything you can do to relieve the problems? No Yes Describe: If No, what have you tried that has not helped? 16. Have you been treated for this before? No Yes How long ago? 17. What treatment did you receive? 18. Results of previous treatment? Good Poor Comments 19. Were you referred to our office by anyone? 20. Is this condition interfering with Work Sleep Daily Routine Recreation None 21. List any other major injuries or traumas you have had, other than those mentioned above: None 22. Any other Musculoskeletal problems? No Yes Neurological problems? No Yes 23. Review of Systems: Neg 24. Medications: None / See Attached List Allergies: None Vitals: L / R Sitting Blood Pressure Pulse BPM Respiration RPM Height ft in Weight Lbs. 27. Surgeries: None Current and Past Health Conditions: None Family History: None Cancer Diabetes HBP Heart Attack/Disease Cholesterol Stroke Arthritis 30. Exercise/Diet Do you exercise? per week No Eat Healthy Y / N Take Vitamins Y / N 31. Tobacco/Alcohol Use: Smoking Yes / No Tobacco Yes / No Drink Alcohol Yes / No Socially I certify that the above information is accurate to the best of my knowledge. Patient/Guardian Signature Date: Joseph A. Sheppard, D.C. Date:

5 Sheppard Chiropractic, Inc McMann Rd. Cincinnati, Ohio (513) REGISTRATION Home Ph Cell Ph Work Ph Best time to call: am/pm Name Street Address City State Zip Social Security Number Sex M F Age Birth date Single Married Widowed Separated Divorced Address Number of Children How and where did you learn about this clinic? Condition / Illness Related To: Illness Employment Automobile Other HIPAA PRIVACY By subscribing my name and signature below, I acknowledge that I have received a copy of the HIPAA guidelines and am in agreement to, and understanding with, its terms and conditions. STATEMENT Signature: Date: AUTHORIZATION I hereby authorize Sheppard Chiropractic, Inc. and whomever they may designate as their clinicians to FOR CARE OF administer care as they so deem necessary to my son/ daughter / ward. A MINOR Signaure of Parent or Guardian: Date: Company Name Occupation EMPLOYER Address Phone Full-time Part-time City State Zip Name SPOUSE Birthdate Social Security Number (PARENT) Employer Name Occupation Address Phone City State Zip Are your present symptoms or conditions related to or the result of an auto accident, work-related injury or personal injury someone else might be legally responsible for? Yes No Your Initials INSURANCE Insurance Company: INFORMATION Policy ID #: Subscriber: Subscriber Date of Birth: Subscriber SSN: PATIENT AGREEMENT 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 and convey directly to Sheppard 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 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 permissable under the law and under 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 permissable 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. Should this assignment be prohibited in part or in whole under any anti-assignment provision of my policy/plan, please advise and disclose to my provider in writing such anti-assignment provision within 30 days upon receipt of my assignment, otherwise this assignment should be reasonably expected to be effective and such anti-assignment is waived. 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 Date

6 SHEPPARD CHIROPRACTIC TERMS OF ACCEPTANCE When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference of the transmission of mental impulses, resulting in a lessening of the body s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specialized in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. I,, have read and fully understand the above statements. Print Name All questions regarding the doctor s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis. Signature Date Consent to evaluate and adjust a minor child. 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. Pregnancy Release This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that an x-ray can be hazardous to an unborn child. Date of last menstrual period: Signature Date

7 PATIENT REQUEST FOR RECORDS DATE: / / PATIENT: ACCT#: DATE OF BIRTH: / / SSN: - - DATE OF RECORDS: These records are needed immediately in order to properly process this patient. Radiology Reports (X-rays, MRI, CT) Films in question: Actual film copies of X-rays / MRI's / CT's (by mail). Office Notes and Dictations Emergency Room Records / Lab Reports / Diagnostic Studies Ambulance Transporter's Report Special Studies (i.e. NCV, EMG, etc.) Surgical / Post-Surgical Reports Other: I HEREBY AUTHORIZE THE RELEASE OF MY X-RAYS / RECORDS AND REQUEST THAT THEY BE TRANSFERRED TO: PATIENT SIGNATURE: DATE: / / Sheppard Chiropractic 3878 McMann Rd. Cincinnati, OH Phone: Fax: Note of Confidentiality: This is intended for use only by the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone, so that all transmitted materials received may be dealt with appropriately. Thank you.

8 DIAGNOSTIC IMAGING CONSULTANTS, INC W. St Route 22-3 Loveland, OHIO (513) FAX: (513) ASSIGNMENT OF BENEFITS FOR RADIOGRAPHIC INTERPRETATION I understand that to insure the highest quality of interpretation of my x-rays, the services of a certified chiropractic radiologist are being utilized. This fee is separate from that of the chiropractic clinic. I also understand that the fees for this service will be submitted to my insurance carrier, Worker s Compensation, or attorney in the case of personal injury. I understand I may receive a billing statement for: insurance denial, professional fees that have been applied to my deductible, or the balance due stated by my insurance company as my responsibility. In the event that I receive payment for the services I agree to promptly remit payment to Diagnostic Imaging Consultants. I acknowledge and give my consent to have my x-rays interpreted by Dr. Bryan Hosler, DACBR. I understand that any balance due is my responsibility. SIGNATURE: DATE: Healthcare information is sensitive information. It is being sent to us after the appropriate authorization of the patient. We the recipient are obligated to maintain it in a safe, secure, and confidential manner. Redisclosure without additional patient consent or as permitted by law is prohibited. Unauthorized disclosure could subject penalties described in federal law. The following signature authorizes the release of medical information and also authorizes the assignment of benefits to: DIAGNOSTIC IMAGING CONSULTANTS, INC West State Route 22-3 Loveland, Ohio SIGNATURE: DATE: WITNESS:

9 SHEPPARD CHIROPRACTIC February 1, 2014 A General Announcement to All Our Patients As a "Courtesy" Sheppard Chiropractic will verify chiropractic benefits on your insurance policy. We do our best to get accurate information, however, you are ultimately responsible for any balance your insurance does not pay. It is your responsibility to know if you have Chiropractic Benefits. Insurance Claims Policy Change As usual, we will continue to file the initial claim for you or your child's chiropractic treatment. Most insurance companies automatically generate continuation of fee payments until the maximum is reached. However, it is increasingly becoming more difficult to get insurance companies to pay. As a result, our insurance department is spending hours and hours trying to get some insurance companies to pay. In some cases, we have been trying for over a year to get a claim paid. Due to this, we will now attempt to get your claim paid for three months. In the fourth month, if your claim has not been paid, you will be responsible to contact your insurance company and have them pay your benefits to us. If you choose not to do this, we will add the amount of uncollected benefit to your portion of the financial contract, and you will be responsible to pay it. If you have any questions feel free to call Maureen or Kristina in the insurance department at (513) Thank you for your cooperation in this matter. X Date: / / 3878 McMann Rd. Cincinnati, Ohio Phone: (513) Fax: (513)

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