Patient Questionnaire Auto-Collision

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1 Patient Questionnaire Auto-Collision Patient Name: (First) (Middle) (Last) (Suffix) Today's Date: / / Birth Date: / / Age: SSN: Gender: (circle) F M Height: ft in Weight: lbs (circle one) Right handed Left handed If you are under 18 years of age, who are your legal parents or guardians? Father: Date of birth: / / Phone: ( ) Mother: Date of birth: / / Phone: ( ) Guardian: Date of birth: / / Phone: ( ) Who do you normally live with? Mother and Father Father Mother Legal Guardian Other Current Address and Information Street: City: State: Zip: Phone: ( ) Cell: ( ) How did you hear about us? Your occupation: Employer: Work Address: Work Phone: ( ) Student at: Full-Time Part-Time Marital Status: Married Separated Divorced Widowed Single How many children? Name of Spouse: Spouse s Date of Birth: / / Spouse s SSN: Spouse s Occupation: Spouse s Employer: Spouse s Work Address: Spouse s Work Phone: ( ) Spouse is a student at: Full-Time Part-Time Who should we contact in the event of an emergency? Phone: ( ) Address of Contact Person:

2 Collision- (Basic Information) Date Collision Occurred: / / Time of Day when Collision Occurred: : AM / PM Describe how the Collision took place: Describe the condition or symptoms caused by the Collision: Collision- (Specific Information) Were you the: Driver Passenger Pedestrian Automobile you were in: Year Make Model Damage to your car: Front Rear Pedestrian Driver Side Passenger Side Bumper Fender Damage amount to your car: Minor Major Totaled Other Automobile Involved: Year Make Model Damage to other car: Front Rear Pedestrian Driver Side Passenger Side Bumper Fender Damage Amount to other car: Minor Major Totaled Where did the accident happen? Street Names: City/State Was it? Controlled Intersection Uncontrolled Not Intersection Was there a traffic light? None Green Red Turn Arrow Stop Sign Were you: Slowly Moving Moving Stopped Weather Conditions: Sunny Rainy Cloudy Street Surface: Dry Wet Slick Icy Pavement Other Type of Impact: Rear end Front Side Impact Roll Over Brakes on Impact: Locked Tight Loosely Applied Foot not on brake How far did your car move upon impact? Did not move Moved 1-10 ft Moved ft Moved over ft Where were you seated in the vehicle: Wearing Seat belt? Yes No Shoulder harness: Yes No Headrest: Yes No Headrest Position: Up Down Is the car equipped with airbags? Yes No Did they deploy? Yes No Did you see the impact coming? Yes No Did you brace yourself for impact? Yes No On impact, your head was looking: Ahead Behind Up Down To the Right To the Left On impact were you: Thrown forward Thrown backwards Thrown sideways Other Did your body hit anything inside the car? Yes No Body Part: What did it hit? Head trauma? Yes No Loss of Consciousness? Yes No For how long? Do you remember the accident happening? Yes No Hospital? Yes No Hospital name: How long were you there? Taken by ambulance? Yes No X-rays taken? Yes No X-ray areas: Neck Mid-back Low-back Other X-rays Medication given? Yes No Rx: Other instructions: Follow-up:

3 Additional Information Related to the Condition: Circle areas of pain on diagram below Describe your pain: Sharp Dull Stabbing Aching Radiating Burning Throbbing Describe the intensity of pain: Minimal Mild Moderate Severe How often do you experience the pain? Infrequent Occasional Intermittent Frequent Constant What caused the pain? What increases the pain? Sitting Standing Walking Running Lifting Time on computer Time on phone Working overhead Sleeping What decreases the pain? Rest Ice Heat Sleeping Sitting Standing Walking Stretching How long has the pain been occurring? Hours Days Weeks Years Has the Patient ever had the same or similar condition or symptoms previous to this most recent occurrence? Yes No When? / / Describe: Please indicate any other healthcare providers that have been seen for the condition or symptoms: Name Type of Licensure Date of Last Visit / / / /

4 Please check any of the following symptoms you are now experiencing: Headache Dizziness Light Bothers Eyes Diarrhea Head seems too heavy Neck Pain Loss of Memory Hands Cold Lightheaded Sleeping Problems Feet Cold Tingling in legs/feet Neck Stiff Face Flushed Tingling in arms/hands Nausea Ears Ring Back Pain Numbness in arms/hands Clumsiness Constipation Nervousness Numbness in legs/feet Loss of Balance Cold Sweats Irritability Tension Loss of Smell Shortness of Breath Chest pain/rib pain Fainting Fever Pain in arms/hands Pain in legs/feet Fatigue Jaw pain Loss of strength - arms Burning muscle pain Loss of strength - legs Difficulty swallowing Sharp/shooting pain Other Have you experienced changes to: Eyes (sight) Ears (hearing) Nose (smell) Mouth (taste) Bladder Bowels Sleep Emotion Appetite Please Explain: Have you missed work or school due to your injuries? Yes No How much time? Any limitations to your normal daily activity? Yes No Please Explain: Medical History: Do you currently smoke? Yes No Have you ever smoked? Yes No Number of packs weekly: Number of packs weekly: When did you quit? / / Do you drink alcohol? Yes No Number of drinks weekly: List any previous accidents (automobile, on the job injuries, slips, falls, sports, etc.) and provide the accident date: 1) / / 2) / / 3) / / Surgeries/Hospitalizations: Allergies (please list all): Do you now or have you ever had: Heart Disease Diabetes Cancer Stroke High Blood Pressure Thyroid Problems Tuberculosis Prostate Disorder Kidney Problems Asthma Ulcer Seizure Disorder Other: WOMEN ONLY: Are you pregnant or is there any possibility you may be pregnant? YES NO UNCERTAIN

5 Personal Injury or Claim Information: Did police arrive on scene of collision? Yes No Citation Issued? Yes No To whom? My Auto Insurance Company: Address: Is MedPay on this policy? Yes No My Group/Individual Insurance Company: Address: Insurance Company of Person Responsible For Injury: Address: Have you been contacted by an insurance adjuster or representative on this claim? Yes No Claim #: Adjuster s Name: Adjuster s Phone: ( ) Adjuster s Fax: ( ) Attorney Name: Address: Phone: ( ) Fax: ( ) How will account be paid: Self pay Auto Insurance Other: I hereby authorize LeRay Chiropractic, PLLC to release medical information if necessary to process this claim. Patient Signature: Date: ***************************************************************************************************************************** ************************************** Payment Expected At Time Of Visit Unless Other Arrangements Have Been Specified I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand LeRay Chiropractic, PLLC will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to LeRay Chiropractic, PLLC will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. Any accounts that are referred for collection will have a service fee charged at the time of referral to cover additional handling costs. Should legal action be necessary for the recovery of any monies due under this agreement, the prevailing party shall be entitled to recover attorney fees and court costs from the other party. Any disputes between parties shall be resolved by binding arbitration. It is not our intention to cause you undue hardship, however we must collect our receivables as efficiently as possible in order to continue our service to the community. Interest of 1.5% per month will be charged on delinquent accounts. If you discontinue care, all charges are due and payable immediately. Patient Signature: Date: / / Patient s Driver s License #: Parent or Guardian Authorizing Care: (print) (sign) ***************************************************************************************************************************** ********************************************

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