Personal Information: Today s Date: Name: I prefer to be called: Address: Health Insurance Information: Do you have Health insurance?

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1 Personal Information: Today s Date: Name: I prefer to be called: Address: Sex Male Female If minor, name of parent or guardian Home Phone: Work Phone: Social Security Number: Date of Birth: Height: Weight: Marital Status: Number of Children: Employer Information: Occupation: Employer: Address: Emergency Contact: Who should we contact in case of Emergency? Phone Number: Relation: Address: Attorney Information: Attorney Name: Phone Number: Primary Care Physician Information: Name Phone Number Health Insurance Information: Do you have Health insurance? Insurance Company: Policy Holder s Name Policy Number Address Phone Number Auto Insurance Information: Do you have Auto Insurance? Insurance Company Policy Number Address Phone Number Adjuster s Name Claim Number Accident Information: Date Time Was it reported to the police? Was a traffic Violation issued? To Whom Location of the accident Number of Passengers Were there other witnesses? Make/Model of vehicle Please explain in detail how the accident occurred: In which direction were you heading?

2 N S E W Approx. speed of the vehicle (MPH) Accident Description Information: Check the description that applies: Actions of the patient s vehicle: Crossing the Stopped at the intersection intersection Stopped for a Stopped for traffic pedestrian Traveling at posted speed limit Turning Traveling faster than speed limit How was your vehicle hit? Hit head on Hit on the right rear Hit on the left front Rear-ended Hit on the right Other: front Hit on the left rear Damage to your vehicle? Complete Minimal Extensive Moderate Describe the second vehicle: Compact Full-Size Mid-Size Semi Trailer Pick up Truck Make: Model: Year: Est. Speed: (MPH) Damage to other vehicle: Complete Extensive Minimal Moderate Weather conditions: Clear Cloudy Drizzling Foggy Rainy Stormy Sunny Road Conditions Damp Dry Snowed over Dry with Ice patches Iced over Wet AT THE MOMENT OF IMPACT Your body position: Leaning Forward Turned to the Left Slouched down in Turned to the Right seat Straight Direction body was thrown : Backward then Forward then Forward backward To the Left To the right About the vehicle Outside vehicle Under vehicle Did any part of your body strike anything in the vehicle? YES Part of Body Part of Vehicle NO Head position at impact: Straight Turned to the Left Tilted Forward Turned to the Right Direction head was thrown; Backward then forward Forward then backward Side to Side Were you by the impact?

3 Aware Surprised Were your brakes? Applied Partially Applied Type of restraint: Lap Belt Shoulder Belt Shoulder Lap Belt Place patient was seated in the vehicle Driver Back passenger right side Front Passenger Back passenger middle Back Passenger Other: driver side Did airbags deploy? YES NO Did the accident render you unconscious? YES, For (length of time) NO Post Injury Information: Were you seen at a medical Facility following your accident? Yes No IF YES please provide the following: Name of the facility: Name of Doctor Type of Doctor: D.C. M.D. D.O. D.D.S Type of Treatment received: Were X-Rays Taken? a) Yes b) No Was an MRI Taken? a) Yes b) No Was a CAT SCAN Taken? a) Yes b) No Was medication prescribed a) Yes (Please list below) b) No How did you get there a) Ambulance b) Private transportation When did you go? a) Immediately b) Next day c) 2 days plus Have you seen any other doctor(s) since the accident? If so please list Have you missed any work since the accident? YES, (Amount NO

4 SYMPTOMS Do you have lacerations, cuts or bruising? Head/Face Neck Seatbelt Bruising Cuts or bruising on chest Cuts or bruising on arms Other: Cuts or bruising on legs Indicate the symptoms that are a result of this accident: Dizziness Memory Loss Headaches Blurred Vision Buzzing in Ear Difficulty sleeping Arm/Shoulder Pain Numb hands/ Fingers Tension Neck Pain Neck Stiff Jaw Problems Irritability Fatigue Chest Pain Short Breath Stomach upset Nausea Back Pain Low Back pain Back Stiffness Leg Pain Numb Feet/Toes Other HEAD INJURIES: Were you knocked out or unconscious Face Pain Dizziness Headaches Pupils different sizes Difficulty Walking Balance Problems Disoriented/ Confusion Attention Problems Change in sense of smell or taste Impatience Memory Problems Appetite Change Visual Disturbances Problems reading or writing Problems learning new things Problems remembering numbers Difficulty remembering things Change in Sexual Functioning Change in Personality Mood Swings Agitation Helplessness Apathy Frustration Room Spins Day Dreaming Hearing Problems Sleepiness Difficulty Speaking Very Tired Sleep Difficulties Flashbacks to incident Problems adding or subtracting Problems understanding Difficulty Concentrating Difficulty making decisions Nausea/Vomiting Wanting to be alone Sadness Anger Reduce Confidence Irritability Other: JAW PROBLEMS: Jaw Pain Clicking Pain while chewing Pain while Talking Pain while yawning Pain moving jaw from side to side NECK INJURIES: Neck Pain Neck Pain, numbness, tingling, weakness that radiates or goes down to RIGHT shoulder, arm,

5 forearm or hand Neck Pain, numbness, tingling, weakness that radiates or goes down to LEFT shoulder, arm, forearm or hand Neck pain, numbness, tingling, weakness that radiates or goes down to RIGHT UPPER BACK Neck pain, numbness, tingling, weakness that radiates or goes down to LEFT UPPER BACK Neck pain that causes headaches Neck spasms or shoulder spasms Popping, clicking or clicking sound with neck movement. SHOULDER INJURIES: Shoulder pain : L R BOTH Shoulder pain with movement L R BOTH Shoulder Spasms: L R BOTH Sharp Shoulder pain Dull Shoulder pain Achy Shoulder pain Pins and needles shoulder pain Shoulder pain that radiates/shoots pain into arm Other: UPPER ARM PAIN: R L BOTH Dull Ache Sharp Stabbing Other: ELBOW PAIN: R L BOTH Dull Ache Sharp Stabbing Other: FOREARM: R L BOTH Dull Ache Sharp Stabbing Other: WRIST PAIN: R L BOTH Dull Sharp Other: Ache Stabbing HAND PAIN: R L BOTH Dull Ache Sharp Stabbing Other: MIDBACK PAIN OR UPPER BACK PAIN: Upper or midback pain Upper back pain, numbness, tingling, weakness that radiates or goes down to RIGHT shoulder, arm, forearm or hand Upper back pain, numbness, tingling, weakness that radiates or goes down to LEFT shoulder, arm, forearm or hand Upper or mid back spasms LOW BACK PAIN Low Back Pain Low Back Pain, numbness, tingling, weakness that radiates o goes down to RIGHT buttock, thigh leg or foot Low back pain, numbness, tingling, weakness that radiates or goes down to LEFT buttock, thigh leg or foot Low back spasms PELVIC OR SACRAL PAIN Pelvic pain, numbness, tingling, weakness that radiates or goes down to RIGHT buttock, thigh leg or foot Pelvic pain, numbness, tingling, weakness that radiates or goes down to LEFT buttock, thigh, leg or foot

6 Sacral pain (tail bone) Coccygeal or coccyx (tail bone) pain HIP PAIN R L BOTH Left Hip Pain Left Hip Pain that radiates or goes down to LEFT buttock, thigh, leg or foot Right Hip Pain Right hip pain, numbness, tingling, weakness that radiates or goes down to RIGHT buttock, thigh, leg or foot UPPER LEG PAIN: R L BOTH Upper leg pain that radiates to knee Upper leg spasms KNEE PAIN: R L BOTH Knee Pain that radiates to calf Knee pain that radiates to calf and ankle Knee pain that radiates to calf, ankle and foot ANKLE PAIN: R L BOTH Ankle pain that radiates to foot Ankle and foot pain FOOT PAIN: R L BOTH CHEST PAIN STOMACH PAIN OTHER SYMPTOMS: Did you ever experience similar symptoms prior to the accident? Yes No Has your condition Improved Worsened Stayed the Same Is the condition affecting your Work Sleep Daily Routine Please indicate your degree of difficulty (on a scale of 1-10, 1 being uncomfortable, 5 being uncomfortable, and 10 being painful) in performing the following activities: Lying on your back Running Lying on Side Sports Lying on Stomach Working Sitting Lifting Standing Bending Stretching Kneeling Sexual Activity Pulling Walking Reaching How many hours are in your normal workday? Please indicate your daily job duties and any activities that you are occasionally asked to perform: Standing Typing Work w/arms above head Driving Bending Crawling Twisting Operating Equipment Lifting Walking Sitting Stooping What positions can you work in with minimum physical effort, and for how long? Do you work with others who can help you with any heavy lifting? While in recovery, are there any light duty tasks you could request?

7 Anemia Ulcer/colonitis Tuberculosis Rheumatic fever Asthma Please list any other medical conditions that you have of have ever had: Please list any allergies: Questionnaire Continued on following page Health History: Have you ever had any of the following diseases or conditions? Heart Congenital Attack/Stroke Heart Defect Alcohol/Drug HIV/AIDS Abuse Freq. Neck Pain High/Low Blood Pressure Severe/Freq Fainting/ Headaches Seizure/Epilepsy Freq. Neck Pain Arthritis Diabetes Lower Back Problems Heart Surgery or Mitral valve collapse pacemaker Venereal disease Shingles Emphysema Psychiatric problems Kidney problems Sinus problems Difficulty Artificial breathing bones/joints Heart murmur Artificial valves Hepatitis Cancer Please list previous surgeries and dates: Please list any past motor vehicle accidents or traumas: Is there anything else about your health history or family health history that you feel is important to share? Do you exercise? Are you on a special diet? Since: / / Do you smoke? How much? How long? Are you wearing?

8 Orthotics Heel Lifts Arch Supports For Women: Are you taking Birth Control? Are you Pregnant? Patient/Legal Guardian Signature: Date:

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