Personal Injury Questionnaire

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1 Personal Injury Questionnaire Name Date of Birth Phone Do you want to be contacted via text: Name of cellphone carrier (ie: T-Mobile): Address City State Zip SSN: Weight & Height: Dominant hand: Employer s Name Employer s Address Your Ins. Co. Policy # Agent s Name Driver/Other Vehicle Ins. Co. Policy # Have you retained an attorney? ( ) Yes ( ) No Were there any witnesses? ( ) Yes ( ) No Name(s) Name(s) Nature of Accident: 1. Date of Accident: Time of Day 2. Were you: ( ) Driver ( ) Passenger ( ) Front Seat ( ) Back Seat 3. Were you struck from: ( ) Behind ( ) Front ( ) Left side ( ) Right side 4. Were you knocked unconscious? ( )Yes ( )No. If yes, for how long? 5. Were police notified? ( ) Yes ( ) No 6. Did you have any physical complaints BEFORE THE ACCIDENT? ( )Yes ( ) No If yes, please describe in detail: 7. Please describe how you felt: a. DURING the accident: b. IMMEDIATELY AFTER the accident: c. LATER THAT DAY d. THE NEXT DAY: 8. Do you have any congenital (from birth) factors which relate to this problem? ( )Yes ( )No. If yes, please describe: 9. Do you have any previous illnesses which relate to this case? ( ) Yes ( ) No If yes, please describe: 10. Have you ever been involved in an accident before? ( )Yes ( )No. If yes, please describe, including date(s) and type(s) of accidents, as well as injuries received. 11. Where were you taken after the accident? 12. Have you ever been treated by another doctor since the accident? ( ) Yes ( ) No. If yes, please list doctor s name and address:

2 What type of treatment did you receive? 13. Since this injury occurred, are your symptoms: ( ) Improving ( ) Getting Worse ( ) Same 14. CIRCLE SYMPTOMS YOU HAVE NOTICED SINCE ACCIDENT: Headache Irritability Numbness in Toes Difficulty Sleeping Feet Cold Neck Pain Chest Pain Shortness of Breath Buzzing in Ears Hands Cold Neck Stiff Dizziness Fatigue Loss of Balance Stomach Upset Sleeping Problems Head seems Too Heavy Depression Fainting Constipation Back Pain Pins & Needles in Arms Lights Bother Eyes Loss of Smell Cold Sweats Nervousness Pins & Needles in Legs Loss of Memory Loss of Taste Fever Tension Numbness in Fingers Ears Ring Diarrhea Symptoms Other Than Above 15. Have you lost time from work as a result of this accident? ( ) Yes ( ) No. If yes, please complete this question. a. Last Day Worked: b. Type of Employment: c. Are you being compensated for time lost from work? ( ) Yes ( ) No. If yes, please state type of compensation you are receiving? 16. Do you notice any activity restrictions as a result of this injury?( ) Yes ( ) No. If yes, please describe, in detail: 17. Other pertinent information (including disease, surgery, or medical condition): I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the Doctor's Office 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 the Doctor's Office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate, any fees for professional services rendered me will be immediately due and payable. I hereby authorize the Doctor to treat my condition as he or she deems. It is understood and agreed the amount paid the Doctor, for x-rays, is for examination only and the x-ray negatives will remain the property of this office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred at this office. Signature Date

3 PATIENT CONSENT FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS follows: here by states that by signing this Consent, I acknowledge and agree as 1. The Practice's Privacy Notice has been provided to me prior to my signing this Consent. The Privacy Notice includes a complete description of the uses and/or disclosures of my protected health information ("PHI") necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out its health care operations. The Practice explained to me that the Privacy Notice will be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this Consent. 2. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law. 3. I understand that, and consent to, the following appointment reminders that will be used by the Practice: a) a postcard mailed to me at the address provided by me; and b) telephoning my home and leaving a message on my answering machine or with the individual answering the phone, or by The Practice may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct its specific health care operations. 5. I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operations. However, the Practice is not required to agree to any restrictions that I have requested. If the Practice agrees to a requested restriction, then the restriction is binding on the Practice. 6. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Practice has already taken action in reliance on this consent. 7. I understand that if I revoke this consent at any time, the Practice has the right to refuse to treat me. 8. I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described to me above and contained in the Privacy Notice, then the Practice will not treat me. I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand. Name of Patient/Individual (Please print) Signature of Legal Representative (e.g., Attorney-In-Fact, Guardian, Parent if a minor) Date Signed Signature of Patient/Individual Relationship to Patient Witness

4 Pain Diagram Mark the areas on this body where you feel the described sensations. Use the appropriate symbols. Mark areas of radiation. Include all affected areas. Numbness Pins & Needles Burning Aching Stabbing xxxxx ***** / / / / / xxxxx ***** / / / / / xxxxx ***** / / / / / Please mark on the pain scale from Zero to 10 the pain you feel with this condition. 10 being the worst pain you have felt with this condition. Pain Chart Neck-Shoulder-Arm-Pain On a scale of zero to 10, I rate my discomfort as follows: ( ) 0 10 no pain severe pain Mid Back Pain On a scale of zero to 10, I rate my discomfort as follows: ( ) 0 10 no pain severe pain Low Back and Leg Pain On a scale of zero to 10, I rate my discomfort as follows: ( ) 0 10 no pain severe pain Date: Patient Signature

5 NOTICE OF DOCTOR S LIEN Patient: Date of Accident: I do hereby authorize Richard Huston, DC to furnish you, my attorney, with full report of his examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was recently involved. I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums as my be due and owing him for medical service rendered me both by reason of this accident and by reason of any other bills that are due his office and to withhold such sums from any settlement, judgment or verdict which may be paid to you, my attorney, or myself, as the result of the injuries for which I have been treated or injuries in connection therewith. I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service rendered me and that this agreement is made solely for said doctor s additional protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, judgment or verdict by which I eventually recover said fee. I agree to promptly notify said doctor of any change or addition or attorney(s) used by me in connection with this accident, and I instruct my attorney to do the same and to promptly deliver a copy of this lien to any such substituted or added attorney(s). Please acknowledge this letter by signing below and returning to the doctor s office. I have been advised that if my attorney does not wish to cooperate in protecting the doctor s interest, the doctor will not await payment but may declare the entire balance due and payable. Date Patient Signature The undersigned being attorney of record for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict, as may be necessary to adequately protect and fully compensate aid doctor above-named. Attorney further agrees that in the event this lien is litigated that the prevailing party will be awarded attorney fees and costs. Date Attorney s Signature Please date, sign and return one copy to doctor s office. Also keep one copy for your records. Doctor Signature Richard Huston, DC Randall Lindstrom, DC 1150 Hungry Neck Blvd. Suite D Mt. Pleasant, SC fax

6 At Atlantic Spine Clinic, your time is valued. Our physicians strive to see patients in a timely manner. We respect your time and ask you to respect our time and other patients needs by keeping your appointment. Each appointment time slot is important and cannot be recovered if a patient chooses not to keep their appointment. We collect fees to ensure that our physicians can continue to see patients. Please keep in mind that each skipped or missed appointment is not just time lost, but also time when other patients cannot be seen. Please refer to the guidelines below to learn more about our Missed Appointment policy: It is your responsibility to provide us with a working telephone number to allow us to communicate important information. Having a valid telephone number is truly important; please help us to maintain your records. Effective April 1 st 2013, each missed appointment will be flagged and you will receive a notice that you have missed your appointment. In addition, your account will be assessed a $25 missed appointment fee. Please note that the fee will not be billed to your insurance. Accounts that accumulate three missed appointment fees may be dismissed from the practice. Any cancellation not made at least 2 hours before the scheduled appointment is considered a missed appointment and subject to the terms above. If you arrive 20 minutes late for your scheduled appointment, without prior notification to our office, this may also be considered a missed appointment. Please remember that communicating with our office is critical to us providing you with quality health care. We understand that circumstances occur that do not allow you to keep your scheduled appointment. If this is the case, please call and discuss this with the office staff as soon as possible. We will waive the cancellation fee for this appointment as long as you do not have a history of cancellations. Our schedule fills up quickly, and this will allow other patients to fill those slots. We realize that there are times that you may arrive for a scheduled appointment time and are not able to be seen promptly at your appointed time. Please know that we go out of our way to make certain that this does not happen, however due to patient emergencies or other unexpected incidents, our schedule may occasionally fall behind. If this is the case, we will make every attempt to let you know the status of our schedule. Name of Patient Signature of Patient Date

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