DOCUMENT PLUS INFORMATION BOOK TABLE OF CONTENTS

Size: px
Start display at page:

Download "DOCUMENT PLUS INFORMATION BOOK TABLE OF CONTENTS"

Transcription

1

2

3 DOCUMENT PLUS INFORMATION BOOK TABLE OF CONTENTS GATHERING DEMOGRAPHIC and PATIENT HEALTH INFORMATION Patient Demographic Sheet with Insurance Verification. pg. 6 Scannable Blue & Green Patient Health Questionnaire pg. 6 After the form is scanned reports can be printed Initial Patient History Summary Report can then be printed for the doctor to review with the patient...pg. 7 ASHN/HMO Insurance Reports, which produces the initial health status patient report for HMO s, can be printed and sent to the insurance company. pgs. 10, 97 Scannable Blue & Pink Automobile Accident Questionnaire.. pg. 12 After the form is scanned reports can be printed Auto Accident Summary Report can then be printed and then sent to the Insurance Company or the Attorney. pg. 13 Narrative Auto Accident Report.. pg. 83, 101 Scannable Brown Accident / Injury Questionnaire. pg. 16 After the form is scanned reports can be printed Accident/Injury Summary Report (used for Auto Accidents, Work Comp and Personal Injury) can then be printed and then sent to the insurance company or the Attorney... pg. 17 Narrative Attorney Accident/Injury Report......pgs. 101, 106, 111 PATIENT FILLED OUT OUTCOME ASSESSMENT QUESTIONNAIRES MEASURING QUALITY OF LIFE CHANGES and ESTABLISHING MEDICAL NECCESSITY Please call us about billing codes specific to the following Questionnaires Scannable Green & Purple Health Status Questionnaire or SF-36. pg. 22 After the form is scanned reports can be printed Measuring Quality of Life / Report of Findings, which helps prove medical necessity, can then be printed and sent to the insurance company... pg. 23 *****CONDITION SPECIFIC SCANNABLE OUTCOME ASSESSMENT FORMS****** pg. 27 Scannable Green & Purple Neck Pain Disability Index Questionnaire After the form is scanned reports can be printed Neck Pain Disability Index Summary, which helps measure activities of daily living, can then be printed and sent to the insurance company.. pg. 28 Reports for letters of medical necessity, initial, re-evaluation and final pg. 73,80, & 95

4 DOCUMENT PLUS INFORMATION BOOK TABLE OF CONTENTS Scannable Green & Purple Roland-Morris Acute Low Back Pain Disability Questionnaire After the form is scanned reports can be printed Roland-Morris Acute Low Back Pain Disability Summary, which helps measure back pain and disability in patients, can then be printed and sent to the insurance company pg. 29 Reports for letters of medical necessity, initial, re-evaluation and final pg. 73,80, & 96 Scannable Green & Purple Revised Oswestry Low Back Pain Disability Questionnaire After the form is scanned reports can be printed Revised Oswestry Low Back Pain Summary, which helps quantify the degree of functional impairment, can then be printed and sent to the insurance company.. pg. 30 Reports for letters of medical necessity, initial, re-evaluation and final pg. 73,81, & 96 NEW PATIENT AND ESTABLISHED PATIENT EXAMINATIONS USING EXAM FORMS Scannable Blue Clinical Evaluation/Re-Evaluation. pg. 32 After the form is scanned reports can be printed Clinical Evaluation/Re-evaluation Summary Report, which provides all the necessary documentation during a new or established patient exam, can then be printed and sent to the insurance company.. pg. 33 Scannable Purple Radiographic Evaluation pg. 40 After the form is scanned reports can be printed Radiographic Evaluation Report, which gives complete report of the X-ray findings, can then be printed and sent to the insurance company..pg. 41 DAILY NOTE FORMS and TRAVEL CARD SYSTEM Please watch DVD to see flow in office Scannable Black & Purple Daily Note Travel Card..Pg. 44 Scannable Black & Purple CBP Daily Note Travel Card.. pg. 50 Daily note forms are loaded in the printer see forms after pg. 44 or pg. 48. Forms are printed out with the patient name and identification number on them. After the form is scanned reports can be printed Daily Notes Paragraph Format. pg. 47 Daily Notes SOAP Format.. pg. 49 Daily Notes CBP Format Postural assessment in objective.. pgs Some Practice Management programs interface with Document Plus. call us about these benefits!

5 Watch the DVD!! DocumentPlus A Solution to the Paperwork Nightmare The increasing demand for documentation by insurance companies and Managed Care have created a nightmare for practitioners. Treating the patient is, and should be, the number one priority. DocumentPlus was created to streamline the paperwork, enhance practice management and assist in practice building. How does one program do all that? Automated forms and a scanner enable the collection of comprehensive information that works with our system to produce the highest quality reports. Our forms facilitate complete documentation and correspondence by using automated doctor's questionnaires, clinical forms, a personal computer, software and scanner. DocumentPlus completes all record keeping effortlessly and instantaneously. The benefits of using DocumentPlus include: 1. Reduction of report to reimbursement turnaround time from insurance companies. 2. Time savings that can increase capacity to handle greater volume. 3. Timely professional reports can increase referrals from patients, other doctors, and attorneys. 4. Working with physicians can increase patient referrals. 5. Quality narratives can create a positive relationship with attorneys. Risk management protection against malpractice litigation. 6. Improving the quality of patient care. This manual and DVD will briefly introduce you to the DocumentPlus system and how it can assist you in your practice. For further information or to place an order call DocumentPlus at today! 1

6 MARKETING: USING THE DOCUMENTPLUS SYSTEM... IN MINUTES Referrals from other Doctors - Doctors using the DocumentPlus system have been able to consistently stimulate referrals from other doctors. For the most part, doctors only learn about another colleague's efficacy of care through quality Initial Consultation Notes, Re-Assessment Reports and Final Reports. By using the DocumentPlus system, you and your staff will be able to create these vital reports quickly and professionally. Additionally, when you use our Outcome Assessment forms you will be able to show statistically your ability to get the patient well and restore or improve their quality of life. The efficacy of care is validated because the quality of care you give is systematically recorded by DocumentPlus. Follow these steps to encourage referrals; 1) Have the patient complete the Health Questionnaire and any other intake forms related to their case. (i.e., Accident Injury, etc.). On the forms the patient has an opportunity to write down all the previous treating doctors in their case and note their primary care physician. (See Patient Forms and Doctor Records.) 2) With the patient's permission send out a Personal Physician Initial Consultation Note to all doctors listed on their intake forms. DocumentPlus will automatically assemble the information from the intake forms, examination findings, radiographic findings, and Outcome Measure forms in a professional report for you or your staff to produce in minutes. Your staff can do this without you having to be present! (See Referring Clinicians.) 3) Follow-up those reports with the Re-Assessment Reports and the Final Report. All reports can be generated by your staff in minutes. 4) Expect Referrals. Referrals from Attorneys - DocumentPlus can help you build your Personal Injury and Workers' Compensation Practice with professional quality documentation. Generally, attorneys contact doctors because they want to either refer a patient, request a report on a patient, or to negotiate fees (usually a reduction in yours.) Doctors using the DocumentPlus system tell us attorney referrals are increasing, the reports requested are easy to produce, and a reduction of fees is not often a request. The following steps will show how DocumentPlus can help you build attorney referrals, make report writing hassle-free, and help cut down on fee reduction requests. 2

7 - Referrals from Attorneys (cont.) 1) Have the patient complete the intake forms necessary for their case. This will ensure the collection of pertinent and consistent data that is vital to excellent report writing. 2) Send the Attorney the Initial Consultation Note along with the appropriate charges for your initial examination and report. Attorneys appreciate not having to wait for reports. Be proactive! Your report will let the attorney know that the patient is under care and the expected duration of treatment. 3) Send the Re-Assessment Consultation Notes to update the Attorney on the patient's progress along with the appropriate charges. This will inform the attorney of the patient's progress and expected conclusion of the case. 4) At the conclusion of the case send the Final Consultation Note including your final bill with the appropriate charges for report writing. As you can see throughout the case the injury, treatment and progress have been documented in a professional and comprehensive manner. This documentation will enable the attorney to build a solid case and allow them to get the best settlement for their client, your patient. This cycle can increase future referrals and increase your income. Referrals from Patients - In addition to those things you already are doing in your office to encourage patient referrals, DocumentPlus can help you to increase those referrals. When a patient comes to you for care, there are basically three things that need to happen for that patient to realize the full benefits of chiropractic care. First, the patient's education must be - moved from a, pain-based understanding of care to a health-oriented, understanding. Next, the patient's perception of their quality of life must improve while under your care. Finally, the patient must follow the care plan that you have set out for them. DocumentPlus can help you achieve these things for your patient by doing the following: 1) Review the information from the Health Questionnaire with the patient. Use of the Outcome Measure forms will give you a baseline to measure current quality of life. (Refer to the section Outcome Measures for more detailed information.) 3

8 Referrals from Patients (cont.) 2) On the second visit to your office, review the patient's Report of Findings with them. (Refer to the Patient Education section.) This report will assist you in detailing the quality of your care to the patient in layman's terms. Patients will appreciate a detailed Report of Findings and often share it with family members and friends. Using the Outcome Assessment forms, you can show your patients statistically where they are in relation to optimal health. By using these reports, you will help your patients to make a connection between their current state of health, and the treatment and care plan needed to restore or improve their quality of life. Involving your patients in this manner will help to establish trust and better understanding. 3) At every re-examination have the patient update the Outcome Measure forms to note changes. This will clearly show their progress and serve as a reminder to stay on the treatment plan. 4) Referrals from family members, co-workers and friends come from the quality of your care and your ability to document your outcomes. The Patient Report Of Findings is a powerful referral tool. HMO. Managed Care, Medicare and Insurance Companies: Effective Communication Using the DocumentPlus system. In this age of reduced fees and reduced services, it is paramount that practitioners take a proactive position to ensure that their patients receive optimal healthcare. When it comes to dealing with insurance companies, doctors and their staffs fight a seemingly unending battle. It almost seems that insurance companies take pleasure in denying a patient care, limiting the number of visits for care, or not paying you for services rendered. How many times have you been asked to reduce your fees, or worse still, your payment has been delayed because you didn't submit the proper documentation? And to add insult to injury, now with Medicare, monetary penalties can be assessed against the practitioner if the documentation fails to support the care given. DocumentPlus was designed specifically to provide you, the practitioner, with all the necessary documentation to avoid those time-consuming and costly aggravations. The DocumentPlus system has even proven its effectiveness in helping doctors collect on outstanding and overdue accounts by using our forms, generating the proper reports, and resubmitting them to carriers who had not pay previously. It is our suggestion that you follow these steps when dealing with HMO's, Managed Care, Medicare or other insurance companies: 1) Produce the Insurance Initial Consultation Note and send it to the insurance companies (prior to them requesting it). Be aggressive and take a positive approach! 4

9 HMO's. Managed Care, Medicare, Insurance Cos. (Cont.) 2) After each patient's re-evaluation, generate and send out the Re-Assessment Consultation Note, and if needed, attach a request for an extended number of patient visits. At this point, the insurance companies will evaluate the need to go beyond their policy guidelines on patient care. The reports produced by DocumentPlus are so thorough and comprehensive, the companies give your patients' cases favorable consideration and will process them expeditiously. By taking a proactive approach, you will build a substantially solid case that should keep your patients from having to suffer an interruption in their treatment because of insurance-imposed visit restrictions. In addition, if you include the Outcome Assessment forms with each re-evaluation, the insurance companies will clearly see that quantitatively, the patient has not been restored to the optimal state of health they enjoyed before the beginning of their case (refer to the Outcome Measures section of this booklet). Lastly, attach the appropriate fees for your service along with the generated DocumentPlus reports. 3) At the conclusion of the case, generate and send the Insurance Final Consultation Report.. NOTE: ATTACH A FINAL BILL WHICH INCLUDES FEES FOR ALL THE EXAMINATIONS AND REPORTS GENERATED FOR THE CASE. LETS GET STARTED! WITH PATIENT INTAKE FORMS The flow of these forms thru the office can be seen on the DVD! 5

10 Gathering Patient Health History Information Using a Health Questionnaire with the Confidential Patient Information Sheet Purple and Black Form When a new patient arrives in your office, they will complete a one page confidential patient questionnaire. This provides the staff with demographic patient information to enter into the patient database and verify insurance benefits. The patient is instructed on how to complete fill the Green & Blue Health Questionnaire. The DocumentPlus system's Health Questionnaire is very similar to the Patient History forms you currently use with two major differences. 1. The form is designed to keep hand written information to a minimum 2. The form can be read by an optical mark scanner. This replaces entering the health history information into a computer and eliminates possible data entry errors in the information. It also eliminates using precious staff time to key in patient information. Your office personnel simply scans the form. (It takes about one second to scan both sides.) Then a complete Patient History Summary can be printed out for you to look over before your patient is ready for their examination. Any handwritten information on the form can be typed in by the staff. Provides a summary of patient's present health status and main concerns Preliminary screening of patient's history Shortens consultation time and promotes patient confidence Eliminates the necessity for office staff and clinicians to interpret patient handwriting and ask repetitive questions Provides permanent documentation in easy-to-read summary form for doctor's records Ensures risk management protection against malpractice litigation (The information from the Health Questionnaire is part of the Attorney Initial Consultation Note, the Attorney Final Consultation Note, the Insurance Initial Consultation Note and Final Consultation Note, the Referring Clinician Initial Consultation Note, the Referred To Initial Consultation Note. And ASHN Reports) 6

11

12

13

14

15

16

17 INITIAL PATIENT HISTORY SUMMARY Patient: Mr. Jon Q. Patient Sex/Age: Male/39 Doctor: Theodore McDaniel Form Date: 10/05/2004 PATIENT'S COMPLAINTS Headaches / Head Pain (symptoms And Related Information) Type Of Pain:...throbbing/pulsating Pain Located:...over parietal bilaterally Began On:...10/02/2004 Headaches Start:...wake up with in morning VAS (0-10):...7 Interrupts Sleep:...sometimes Brought On By:...physical activity Frequency:...six times per week Duration:...1 to 3 hours Relieved By:...NSAIDS medication and lying down Spine (symptoms) Neck (both sides): severe, burning pain with stiffness and soreness occurring constantly that is worsening Ribs (left side): moderate pain occurring constantly that is unchanged Ribs (right side): moderate pain occurring constantly that is unchanged Upper Extremities (symptoms) Shoulder (left side): severe, throbbing pain with weakness occurring frequently that is worsening Arm (left side): severe pain with numbness, tingling, and weakness occurring frequently that is worsening Forearm (left side): numbness, tingling, and weakness occurring frequently that is worsening Wrist (left side): tingling and weakness occurring frequently that is worsening Hand/Fingers: tingling and weakness occurring frequently that is worsening Lower Extremities (symptoms) Knee (left side): severe, throbbing pain occurring frequently that is unchanged Ankle (right side): moderate, throbbing pain occurring constantly that is worsening Foot: moderate, throbbing pain occurring constantly that is worsening 7

18 Spine, Upper Extremities, and Lower Extremities (related Information) Symptoms Began:...suddenly on 10/02/2004 Complaints Caused By:..auto accident VAS (0-10):...8 Worsened By:...reaching, standing, sneezing, lifting, pulling motions, bending, walking, and turning motions Relieved By:...rest, taking medications, and hot baths Treated Outside Office:..yes, evaluation and treatment performed by Dr. Ron Johnson;10/03/2004 Pre-existing Conditions:.no Denies Changes In:...bowel, bladder, or sexual function Additional Complaints And Symptoms The patient also complains of having chipped a tooth in the accident. Doctor's Notes MEDICAL HISTORY Medical Care Family Physician:...Dr. Ron Johnson Eastside Ave. Atlanta, Ga last physical exam 07/14/2004 Reported The Following Hospitalization:...not hospitalized in the past five years Surgery:...no surgery in the past five years Auto Accident:...10/02/2004 Conditions/Illnesses Currently Has:...no conditions or illnesses Previously Had:...sinus trouble MEDICATIONS Supplements:...multivitamin Anti-Inflammatory:...for neck and back pain Drug Allergies:...none FAMILY HISTORY Significant For Father:...diabetes and kidney disease Mother:...heart trouble, back problems, and disc problems 8

19 SOCIAL HISTORY Personal Information Age: 39 Date Of Birth:...07/29/1965 Sex:...male Marital Status:...married Children:...two Resides With:...spouse and children Dexterity:...right-handed Activities/Habits Exercises:...1 to 2 days per week; engages in jogging, golf, and strength training Smoking:...never Caffeinated Beverages:...1 to 2 cups/glasses per day Alcohol Consumption:...never Drugs/Substance Abuse:.never OCCUPATIONAL INFORMATION - ACTIVITIES OF DAILY LIVING Employment Status:...full time employee Time At Work:...8 hours per day; 5 days per week Length Of Employment:.12 years and 3 months Current Complaints:...do affect hours worked Job Involves Lifting:...frequently, 20 pounds Location:...standing at a counter Movement:...bending, stooping, walking, repetitive hand use, twisting, and carrying Work Characterized:...light manual labor Stress Level:...moderate Aggravate Complaints:...yes, patient is unable to bend down or lift REVIEW OF SYSTEMS Reported The Following Conditions Or Problems: General:...fatigue, weakness, and continued loss of sleep Neurologic:...headaches, dizziness, and depression Gastrointestinal:...decreased appetite 9

20 ASHN REPORTS!! THE GREEN AND BLUE HEALTH QUESTIONAIRE ALSO PRODUCES THE INITIAL HEALTH STATUS PATIENT REPORT FOR HMO S PRINTED IT OUT TO SAVE PATIENT AND STAFF FROM RE-ENTERING DATA Enter key patient information once not several times!! (Chiropractic) Fax: Patient Name: Smith, Jon Q Birthdate: 07/29/1965 Sex: M Address: 123 Strafford Place City: Mesa State: AZ Zip: Telephone: (770) Social Security #: Driver Lic. #: B Occupation: salesman Employer: ABC Company WorkPhone: (800) Address: 48 Davis Ave. City: Mesa State: AZ Zip: Subscriber Name: Smith, Jon Q Health Plan: American Specialty Health Plans (ASHP) Subscriber ID#: 4998 Group #:: Spouse Name: Mary D. Smith Spouse Employer: City: State: Zip: MARK AN X ON THE PICTURE WHERE YOU HAVE PAIN OR OTHER SYMPTOMS. DESCRIBE YOUR CURRENT PROBLEM AND HOW IT BEGAN: Neck on both sides severe, burning pain with stiffness and soreness occurring constantly that is worsening. Rib cage on left side moderate pain occurring constantly that is unchanged. Rib cage on right side moderate pain occurring constantly that is unchanged. Left shoulder severe, throbbing pain with weakness occurring frequently that is worsening. Left arm severe pain with numbness, tingling, and weakness occurring frequently that is worsening. Left forearm numbness, tingling, and weakness occurring frequently that is worsening. Left wrist tingling and weakness occurring frequently that is worsening. Left hand/fingers tingling and weakness occurring frequently that is worsening. Left knee severe, throbbing pain occurring frequently that is unchanged. Right ankle moderate, throbbing pain occurring constantly that is worsening. Right foot moderate, throbbing pain occurring constantly that is worsening. Problem began suddenly and was the result of an auto accident. Throbbing/pulsating pain from headaches over parietal area bilaterally. Headaches occur six times per week and last 1 to 3 hours. Is this? Work Related Auto Related N/A DATE PROBLEM BEGAN: 10/02/2004 Current complaint (how you feel today): X No Pain Unbearable Pain How often are your symptoms present? 0-25% 26-50% 51-75% % 10

21 Can you perform your daily activities? Yes No (Describe) HAVE YOU HAD SPINAL X-RAYS, MRI, CT SCAN? No Yes Date(s) taken: WHAT AREAS WERE TAKEN? Please check all of the following that apply to you: Past Present Condition Past Present Condition History of Recent Infection Prostate Problems Fever Frequent Urination HIV/AIDS Pregnancy, # of births Diabetes Abnormal Weight Gain Loss Corticosteroid Use Epilepsy/Seizures Birth Control Pills Visual Disturbances High Blood Pressure Low/Mid Back Pain Stroke (date) Neck Pain Dizziness/Fainting Arthritis Numbness in Groin/Buttocks Alcohol Use Urinary Retention Tobacco Use Aortic Aneurysm Surgeries/Medications: Anti-inflammatory. Cancer/Tumor Osteoporosis Trauma Family History: Cancer Diabetes High Blood Pressure Cardiovascular Problems/Stroke I certify that the above information is complete and accurate. If the health plan information is not accurate, or if I am not eligible to receive a health care benefit through this provider, I understand that I am liable for all charges for service rendered and I agree to notify this doctor immediately whenever I have changes in my health condition or health plan coverage in the future. Patient Signature: Date: ASHN HMO INITIAL AND RE-EVALUATION COMPREHENSIVE REPORTS CAN BE SEEN IN THE INSURANCE SECTION OF THIS BOOK 11

22 Gathering Patient Information Using an Automobile Accident Questionnaire If your patient has been in an automobile accident, you need to have as much information as possible regarding what happened in the accident to make the best decisions regarding treatment. The patient completes this form which provides detailed information about the accident and the patient's own interpretation of what happened to them. After scanning the form, you will have a summary of all the circumstances involved. The information is also available in detailed narrative format for reports to the insurance company and the patient's attorney. Provides easy-to-read summary of the accident for your patient medical records Generates documentation in narrative form for the patient's attorney regarding the details of the accident Estimates the necessity of office staff and clinicians to interpret patient handwriting and ask repetitive questions Heightens the awareness of the patient of possible connections between injuries and the accident Increases referrals from attorneys and other clinicians due to the timely professional reports provided (The information from the Automobile Accident Questionnaire is also used in the Attorney Initial Consultation Note and the Attorney Final Consultation Note.) 12

23

24

25 AUTOMOBILE ACCIDENT - SUMMARY Patient: Mr. John Q Patient Sex/Age: Male / 39 Doctor: Theodore McDaniel Form Date: 10/05/2004 VEHICLE PATIENT WAS IN Type And Size Mini van Patient's Location Right rear passenger What Vehicle Was Doing Slowing down for a traffic light Damage Sustained Extensive FIRST VEHICLE TO STRIKE Type And Size Full-size Ford Excursion How It Struck Rear ended Damage Sustained Minimal CONDITIONS AT TIME OF ACCIDENT Time Of Day Daylight Road Condition Dry Visibility Good TRAFFIC CITATIONS ISSUED Driver of other vehicle 13

26 AT MOMENT OF IMPACT Preparation For Accident Complete surprise Use Of Restraints Restraint belts: not wearing Headrests: none Air bags: not equipped Body Position And Thrown Position: straight Thrown: forward then backward Head / Neck Position And Motion Position: straight Motion: forward then backward RESULT OF IMPACT What Body Parts Struck Against Head: front seat Upper left extremities: an unattached metal bar in the van Torso: front seat Lower right extremities: an unsecured piece of wood in the van See narratives in attorney & insurance reports 14

27 Accident Injury Questionnaire For Auto Accident Work Comp And Personal injury 15

28 Gathering Patient Information Using an Accident/Injury Questionnaire (Purple and Black Form) If your patient has suffered an injury or been in an accident, they would fill in the DocumentPlus Accident/Injury Questionnaire. This form allows for detailed subjective information to be available to you after it is scanned. The information will include the date and time of the accident, as well as a description of the accident and the treatment received at the accident site or the hospital. The information also includes consequential development of symptoms after the accident and data as to whether the patient is restricted in any area or has missed work because of the accident/injury. Provides concise report of the circumstances surrounding the accident/injury Produces detailed narrative format for medical legal narratives in language which meets legal criteria and workers' compensation requirements Generates summary report for the patient's medical records Increases potential referrals from attorneys and other clinicians from the professional and timely reports sent Information required by the insurance companies and attorneys from the clinician is provided effortlessly by the patient (The information from the Accident Injury Questionnaire is used in the Attorney Initial Consultation Note and the Attorney Final Consultation Note.) 16

29

30

31

32

33 ACCIDENT/INJURY - SUMMARY Patient: Mr. John Q Public Sex/Age: Male / 39 Doctor: Theodore McDaniel Exam Date: 10/05/2004 DATE AND TIME OF ACCIDENT/INJURY Date And Time 10/04/2004 at 5:18 pm DESCRIPTION OF ACCIDENT/INJURY Type Of Accident/Injury Motor vehicle accident IMMEDIATELY AFTER ACCIDENT/INJURY Loss Of Consciousness No Patient Felt Confused Dazed Immediate Pain Lower back Left elbow Emergency Care At Site Received emergency care Destination After Accident/Injury Patient went to hospital Driven by ambulance HOSPITAL VISIT AFTER ACCIDENT/INJURY Hospital Information Mr. McDaniel went to Community Hospital Immediately after accident/injury Examined by Dr. Donald Jacobs Not admitted 17

34 X-Rays Taken Of Head Neck Upper/middle back Lower back Pelvis Rib cage Left arm Left elbow Diagnosis Neck: contusions Upper/middle back: contusions Lower back: contusions Treatment Administered Ice packs Instruction Given Told to see: general practitioner Recommendations made: Ice Heat Medication prescribed for: pain FOLLOWING THE ACCIDENT/INJURY When Additional Symptoms Developed A few days after Additional Symptoms Pain: Neck Lower back Left arm Right knee Stiffness: Neck Lower back Left arm Left elbow Left forearm Right knee Numbness: Left arm Left elbow Left forearm Left wrist 18

35 Since Accident/Injury Patient Has Experienced: Dizziness Headaches Restlessness Insomnia Restrictions As A Result Of Accident/Injury In Daily living Recreational activity Work function Work Status Due To Accident/Injury Missed work from 10/03/2004 to present Self Treated Symptoms With Bed rest Reason For Seeking Today's Consultation Worsening of symptoms INSURANCE/ATTORNEY INFORMATION Filed: accident/injury report To see in narrative form look at attorney & insurance reports 19

36 Outcome Measures The healthcare and legal systems are moving into an era of assessment and accountability. The emerging tools for measuring the effectiveness of patient treatment procedures are the Outcome Assessment forms. These assessment tools offer a statement of both subjective and objective data. The patient completes the form on the appropriate visit, your staff scans it into the system and the data is incorporated into existing reports for insurance companies or attorneys. In a matter of minutes you can establish validity, responsiveness and reliability of treatment! DocumentPlus has four Outcome Assessment forms that should be administered in conjunction with your examination and re-examination procedures to provide a detailed assessment of the patient's progress over time. Health Status Questionnaire - This questionnaire, established by the Health Outcomes Institute, is a measure of overall functional status, well-being and risk of depression for adults. The form measures eight specific health attributes grouped under three major health dimensions (Functional Status, Well-being, and Overall Evaluation of Health). The Health Status Questionnaire should be incorporated as part of the routine initial exam on each new patient. Neck Pain Disability Index Questionnaire - Designed to measure the activities of daily living in persons with neck pain. The average patient will be able to complete it in five to ten minutes. Roland-Morris Acute Low Back Pain Disability Questionnaire - This form is designed to be a simple and accurate measure of assessing back pain and disability in patients with completion time of approximately five minutes. Revised Oswestry Chronic Low Back Pain Disability Questionnaire - This is a self- administered subjective questionnaire that quantifies the degree of functional impairment of individuals with low back pain. The Oswestry is a well-known outcome measure used in evaluating the effectiveness of treatment protocols. It can also be used for screening and treatment planning. The amount of time required to complete this particular form is minimal. Sample forms are enclosed along with sample output. When the outcome assessment forms have been used, that data is available for use in all attorney and insurance and letter of medical necessity reports. 20

BOYER CHIROPRACTIC INC

BOYER CHIROPRACTIC INC Patient Name: Birthdate: Sex: M / F Address: City: State: Zip: Telephone: Social Security #: Driver Lic. #: Occupation: Employer: Work Phone: Address: City: State: Zip: Subscriber Name: Health Plan: Subscriber

More information

Auto Accident Questionnaire

Auto Accident Questionnaire Auto Accident Questionnaire Patient s Name: Date Of Accident: Date: Social History: (please complete the following, check all boxes that apply) Are you: Married Single Divorced Widowed # of Children: #

More information

Patients Signature Date. Guardian or Spouse s Signature who authorize care. Phone#: Relationship Phone#:

Patients Signature Date. Guardian or Spouse s Signature who authorize care. Phone#: Relationship Phone#: Hands On Chiropractic I understand and agree that health and insurance policies are an arrangement between an insurance carrier and my self. Furthermore, I understand Hands On Chiropractic will prepare

More information

LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B

LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B 1 Patient Name In order to properly assess your condition, we must understand how much your BACK/LEG (SCIATIC) PAIN has affected your ability to manage everyday activities. For each item below, please

More information

Quality of Life. Questionnaire 3. 4 weeks after randomisation. Graag in laten vullen door geincludeerde patiënt METEX studie

Quality of Life. Questionnaire 3. 4 weeks after randomisation. Graag in laten vullen door geincludeerde patiënt METEX studie Patient registration label Quality of Life Questionnaire 3 4 weeks after randomisation Graag in laten vullen door geincludeerde patiënt Patient Identification Number Datum van invullen 1 SF-36 HEALTH SURVEY

More information

Upper Arm. Shoulder Blades R L B R L B WHICH SIDE IS MORE PAINFUL? (CERVICAL PAIN SIDE) RIGHT LEFT EQUAL NOT APPLICABLE (N/A) CERVICAL.

Upper Arm. Shoulder Blades R L B R L B WHICH SIDE IS MORE PAINFUL? (CERVICAL PAIN SIDE) RIGHT LEFT EQUAL NOT APPLICABLE (N/A) CERVICAL. 1 NECK PAIN Patient Name In order to properly assess your condition, we must understand how much your NECK/ARM problems has affected your ability to manage everyday activities. For each item below, please

More information

ACTIVITY LEFT ARM RIGHT ARM

ACTIVITY LEFT ARM RIGHT ARM SHOULDER ASSESSMENT FORM AMERICAN SHOULDER AND ELBOW SURGEONS Side: R L Device: RSP TSA Hemi DOS: Side: R L Device: RSP TSA Hemi DOS: Circle the number in the box that indicates your ability to do the

More information

Questions Concerning Activities of Daily Living (ADL)

Questions Concerning Activities of Daily Living (ADL) Questions Concerning Activities of Daily Living (ADL) Please fill out this form carefully and mark only one box for each question. 1. How well can you perform personal self care activities including washing,

More information

History Questionnaire

History Questionnaire History Questionnaire Today s Date Physician Patient Information Patient s Name Is this your legal name? Street Address Mr. Miss. Marital Status (circle one) Mrs. Ms. Single Mar Div Sep Wid If not, what

More information

CRITÉRIOS DE AVALIAÇÃO DE QUALIDADE DE VIDA

CRITÉRIOS DE AVALIAÇÃO DE QUALIDADE DE VIDA CRITÉRIOS DE AVALIAÇÃO DE QUALIDADE DE VIDA S1 SF36 General Health Survey Patient Name Patient ID Study Name Study Number Date / / Side Right Left Filled in by: Operating Dr. Other MD Research Assistant

More information

Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF-36)

Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF-36) Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF-36) bout: The SF-36 is an indicator overall health status. Items: 10 Reliability: Most se studies that examined reliability SF_36 have

More information

Medical Massage Client Intake Form Medical Massage Client Intake Form

Medical Massage Client Intake Form Medical Massage Client Intake Form Medical Massage Client Intake Form Medical Massage Client Intake Form Client Name: Date: Please note: The more information you are able to provide, the better equipped our therapists will be to help you.

More information

The RAND 36-Item Health Survey

The RAND 36-Item Health Survey The RAND 36-Item Health Survey Introduction The RAND 36-Item Health Survey (Version 1.0) laps eight concepts: physical functioning, bodily pain, role limitations due to physical health problems, role limitations

More information

Patient Basic Information

Patient Basic Information Patient Basic Information Personal Information: Last Name: First Name: Mid. Init.: Address: City, State, Zip: Home Phone: Work Phone: Social Security No.: Date of Birth: Date of Injury/Onset: Dominant

More information

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340 Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional

More information

BIRTHDATE - - AGE SEX EMERGENCY CONTACT PHONE( )

BIRTHDATE - - AGE SEX EMERGENCY CONTACT PHONE( ) PATIENT INFORMATION SOCIAL SECURITY # MARRIED SINGLE WIDOW DIVORCED NAME Last First MI HOME ADDRESS BILLING ADDRESS ACCT# DRIVER S LICENSE# BIRTHDATE - - AGE SEX CITY STATE ZIP CITY STATE ZIP PHONE HOME(

More information

Cervical Spine. New Patient Form

Cervical Spine. New Patient Form Cervical Spine New Patient Form Please mark the painful areas on the pictures below Use the following marks: stabbing pain ooo burning pain +++ aching pain pins and needles = = = numbness Right Right Right

More information

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.

More information

City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:

City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip: Name: Mailing Address: First M.I. Last Today s Date: Physical Address: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: Employer: Occupation: Employer s Address: Work

More information

BAILEY CHIROPRACTIC LIFE CENTER

BAILEY CHIROPRACTIC LIFE CENTER BAILEY CHIROPRACTIC LIFE CENTER Jason A. Bailey, D.C. 224 Southpark Circle East St. Augustine, FL 32086 904-342-4941 Name: Male Female Today s Date: Address: City/State/Zip: Home Phone: ( ) Cell Phone:

More information

Gilbert Varela, M.D., Inc 5232 E. Beverly Boulevard Los Angeles, California 90022 Phone: (323) 724-6911 Fax: (323) 724-6915

Gilbert Varela, M.D., Inc 5232 E. Beverly Boulevard Los Angeles, California 90022 Phone: (323) 724-6911 Fax: (323) 724-6915 Gilbert Varela, M.D., Inc 5232 E. Beverly Boulevard Los Angeles, California 90022 Phone: (323) 724-6911 Fax: (323) 724-6915 September 10, 2007 Law offices of xxxxxxxxx Santa Monica, CA 90405 REGARDING:

More information

DEL MAR PHYSICAL THERAPY Patient Information

DEL MAR PHYSICAL THERAPY Patient Information PLEASE PRINT CLEARLY DEL MAR PHYSICAL THERAPY Patient Information Name Birthdate Last First M.I. MM/DD/YYYY Age Sex M / F Marital Status SS# Address City Zip Phone ( ) Work ( ) Cell ( ) Email **********************************************************************************

More information

Insurance Information

Insurance Information Patient File#: AUTO ACCIDENT HISTORY WELCOME: The doctor and staff welcome you and want you to provide you with the best possible care. We will conduct a thorough history and physical examination to decide

More information

CHAMBERS MEDICAL GROUP 5108 15th Street East, Suite 205 * Bradenton, FL 34203 * (941) 727-9057 * (941) 727-3981 fax

CHAMBERS MEDICAL GROUP 5108 15th Street East, Suite 205 * Bradenton, FL 34203 * (941) 727-9057 * (941) 727-3981 fax CHAMBERS MEDICAL GROUP 5108 15th Street East, Suite 205 * Bradenton, FL 34203 * (941) 727-9057 * (941) 727-3981 fax PERSONAL INFORMATION: PLEASE PRINT MISS/MRS/MS/MR: AGE: FIRST MIDDLE MAIDEN LAST DATE

More information

Patient Questionnaire Auto-Collision

Patient Questionnaire Auto-Collision 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

More information

ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE

ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE NAME: DATE: ADDRESS: AGE: TELEPHONE#: RELIGION: OCCUPATION: REFERRED BY WHOM: NEAREST FRIEND/RELATIVE: TELEPHONE#: ADDRESS: PLEASE EXPLAIN WHY YOU HAVE COME TO SEE

More information

Motor Vehicle Accident - New Patient

Motor Vehicle Accident - New Patient Motor Vehicle Accident - New Patient Today's Date: Patient Name: Auto Insurance Company of Car You Were In: Phone: Insurance Agent: Phone Was A Police Report Made? Have You Informed Your Agent of Your

More information

Potomac Valley Chiropractic Personal Injury

Potomac Valley Chiropractic Personal Injury Potomac Valley Chiropractic Personal Injury Spiro Theodore, D.C. 12105 Darnestown Road, L8 Gaithersburg MD 20878 Please Complete all applicable fields Date: -------------------------------------------------------DEMOGRAPHICS--------------------------------------------------------------

More information

WORKERS COMPENSATION INTAKE FORM

WORKERS COMPENSATION INTAKE FORM WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,

More information

PERSONAL INFORMATION

PERSONAL INFORMATION Date: Bruns Chiropractic Clinic EXISTING PATIENT INTAKE FORM (For patients treated within the past 3 years) PERSONAL INFORMATION Name: First MI Last Preferred Name: Gender: M F DOB: / / Age Social Security

More information

PATIENT NAME: AGE: ACCOUNT NO.: Ache XXXXXX 0% 100%

PATIENT NAME: AGE: ACCOUNT NO.: Ache XXXXXX 0% 100% AGE: DATE OF VISIT: TIMEPOINT: Mark these drawings according to where you hurt. If the back of your neck hurts, mark the drawing on the back of the neck, etc.) If you feel any of the following symptoms,

More information

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340 Medicare Insurance Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning

More information

Auto Accident/Personal Injury Information

Auto Accident/Personal Injury Information Auto Accident/Personal Injury Information Patient s Name: Today s Date: Personal Injury Information Date of Accident: Time of Accident: am/pm Did police arrive on scene? [ ] Yes [ ] No Is there a report?

More information

Gary E. Lee, D.C. Chiropractic Physician 6216 South Redwood Road, Salt Lake City UT 84123 (801) 974-5555

Gary E. Lee, D.C. Chiropractic Physician 6216 South Redwood Road, Salt Lake City UT 84123 (801) 974-5555 Gary E. Lee, D.C. Chiropractic Physician 6216 South Redwood Road, Salt Lake City UT 84123 (801) 974-5555 General information: Name Today s date of Accident Time of Accident Marital status: r Married r

More information

CHIEF COMPLAINT: Please number your symptoms (1 is the most severe) that you have developed since the accident.

CHIEF COMPLAINT: Please number your symptoms (1 is the most severe) that you have developed since the accident. VANCE CHIROPRACTIC PERSONAL INJURY QUESTIONAIRE (PLEASE BE VERY SPECIFIC WITH YOUR ANSWERS THANK YOU!) Last Name First Name Middle Home Phone Work Phone Street Address and Number Mailing Address if Different

More information

Patient Information. Last Name: First Name: Middle Initial: Address: Apt No: City: State: Zip: Home Phone: Work Phone: Social Security No.

Patient Information. Last Name: First Name: Middle Initial: Address: Apt No: City: State: Zip: Home Phone: Work Phone: Social Security No. Patient Information Patient Information Last Name: First Name: Middle Initial: Address: Apt No: City: State: Zip: Home Phone: Work Phone: Social Security No.: Alternate Phone (cell / pager): e-mail: Date

More information

PERSONAL INJURY QUESTIONNAIRE. NAME: Date of Accident

PERSONAL INJURY QUESTIONNAIRE. NAME: Date of Accident PERSONAL INJURY QUESTIONNAIRE NAME: Date of Accident Where did accident happen? Describe the accident in your own words: What was your position in the car? Driver: if Driver were your hands on the steering

More information

Auto Accident Description

Auto Accident Description Automotive Accident Form Billing Information Patient name: Date of injury: Time of injury: AM PM City and street where accident occurred: What is the estimated damage to your vehicle? $ Do you have automobile

More information

Case Studies Updated 10.24.11

Case Studies Updated 10.24.11 S O L U T I O N S Case Studies Updated 10.24.11 Hill DT Solutions Cervical Decompression Case Study An 18-year-old male involved in a motor vehicle accident in which his SUV was totaled suffering from

More information

Accident / Injury Report

Accident / Injury Report Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. Auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked?

More information

ACCIDENT HISTORY QUESTIONNAIRE

ACCIDENT HISTORY QUESTIONNAIRE ACCIDENT HISTORY QUESTIONNAIRE PATIENT INFORMATION Name Date Address City State Zip Code DOB Age SS# Marital Status Sex Male Female How did you hear about the office? Home Phone Work Phone Employer Occupation

More information

Acute Low Back Pain. North American Spine Society Public Education Series

Acute Low Back Pain. North American Spine Society Public Education Series Acute Low Back Pain North American Spine Society Public Education Series What Is Acute Low Back Pain? Acute low back pain (LBP) is defined as low back pain present for up to six weeks. It may be experienced

More information

Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081

Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081 Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081 PLEASE COMPLETE ALL OF THE INFORMATION. REFERRED BY: LAST NAME MIDDLE FIRST STREET ADDRESS CITY STATE ZIP CODE HOME PHONE ( ) - WORK ( )

More information

Personal Injury Intake Form

Personal Injury Intake Form Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of

More information

A Patient s Guide to Diffuse Idiopathic Skeletal Hyperostosis (DISH)

A Patient s Guide to Diffuse Idiopathic Skeletal Hyperostosis (DISH) A Patient s Guide to Diffuse Idiopathic Skeletal Hyperostosis (DISH) Introduction Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a phenomenon that more commonly affects older males. It is associated

More information

Dear Patient, Sincerely, Your Spine Team. Alan Dacre, M.D. Jennifer Kuhr PA-C Michael Guiles PA-C

Dear Patient, Sincerely, Your Spine Team. Alan Dacre, M.D. Jennifer Kuhr PA-C Michael Guiles PA-C Dear Patient, Adult Reconstruction Hip & Knee Dean C. Sukin, MD John R. Wilson, MD Foot & Ankle Michael R. Yorgason, MD General Orthopedics John R. Dorr, MD Hand & Upper Extremity Ralph M. Costanzo, MD

More information

Accident / Injury Report

Accident / Injury Report Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked

More information

ASSIGNMENT OF BENEFITS. CLAIM # Insurance Co. Name + Address INJURY HISTORY. Patient s Name Today s Date

ASSIGNMENT OF BENEFITS. CLAIM # Insurance Co. Name + Address INJURY HISTORY. Patient s Name Today s Date Page 1 out of 7 AUTO INJURY HISTORY FORM Missing / Incomplete / Inaccurate information may jeopardize your coverage by the insurance carrier or future legal documentation ASSIGNMENT OF BENEFITS The information

More information

Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )

Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( ) Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Preferred Contact Method: Home Ph Mobile Ph Text E-mail

More information

(STREET) (CITY) (STATE) (ZIP) DOB: / / Soc. Sec # : - - Employer Address: (STREET) (CITY) (STATE) (ZIP)

(STREET) (CITY) (STATE) (ZIP) DOB: / / Soc. Sec # : - - Employer Address: (STREET) (CITY) (STATE) (ZIP) PATIENT INFO Name: Address: (LAST) (MI) (FIRST) (STREET) (CITY) (STATE) (ZIP) Home Phone: Work Phone: Cell Phone: Email Address: DOB: / / Soc. Sec # : - - Driver s License #: State: Marital Status: S M

More information

Medical Report Prepared for The Court on

Medical Report Prepared for The Court on Medical Report Prepared for The Court on Mr Sample Report Claimant's Address Claimant's Date of Birth Instructing Party Instructing Party Address Instructing Party Ref Solicitors Ref Corex Ref 1 The Lane

More information

Temple Physical Therapy

Temple Physical Therapy Temple Physical Therapy A General Overview of Common Neck Injuries For current information on Temple Physical Therapy related news and for a healthy and safe return to work, sport and recreation Like Us

More information

LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP OCCUPATION EMPLOYER/SCHOOL WORK PH

LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP OCCUPATION EMPLOYER/SCHOOL WORK PH PLEASE PRINT PATIENT INFORMATION TODAY S DATE: LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP E-MAIL HOME CELL OCCUPATION EMPLOYER/SCHOOL WORK SOCIAL SECURITY NO SEX: M / F DATE OF BIRTH MARITAL STATUS:

More information

Function First Physical Therapy, P.C. Patient Intake Form

Function First Physical Therapy, P.C. Patient Intake Form Patient Intake Form Patient Information: Last Name: First Name: Sex: Date of Birth: SS#: - - Address: City: State: Zip Code: Work#: ( ) - Home#: ( ) - Email: Mobile#: ( ) - Marital Status: Single Married

More information

*Date of injury/auto Accident/Slip and fall: / / Time: : AM PM

*Date of injury/auto Accident/Slip and fall: / / Time: : AM PM Oasis Chiropractic Injury/ Auto Accident/ Slip & Fall Form First Name: Last Name: Title: (check one) Mr. Mrs. Ms. Miss Dr. Other Patient ID#: Single Married Widowed Under 18 (Minor) Separated Divorced

More information

Auto Accident Questionnaire. Auto Insurance Information (please present a copy of your auto insurance card)

Auto Accident Questionnaire. Auto Insurance Information (please present a copy of your auto insurance card) Auto Accident Questionnaire name today s date date of accident date of birth age gender marital status # of children address street city state zip home phone cell phone email occupation company name city

More information

Dr. Paul S. Baird 785 E. 200 S. Ste. 6A, Lehi 801-766-4741. Patient Name: Date of Accident: Time of Accident:

Dr. Paul S. Baird 785 E. 200 S. Ste. 6A, Lehi 801-766-4741. Patient Name: Date of Accident: Time of Accident: Dr. Paul S. Baird 785 E. 200 S. Ste. 6A, Lehi 801-766-4741 Auto Accident Section Patient Name: Date: Date of Accident: Time of Accident: Daylight Dawn Dusk Dark Injury History: Were you: Driver Front Seat

More information

PERSONAL INJURY CASE HISTORY

PERSONAL INJURY CASE HISTORY Name: Mowry Chiropractic Inc. 240 North Liberty Street, Powell, OH 43065 (614) 436-9070 (p) ~ (614) 436-8803 (f) PERSONAL INJURY CASE HISTORY 1. Circle the severity (0 = No Pain to 10 = Very Severe Pain)

More information

DEMOGRAPHIC FORM PATIENT INFORMATION. Mailing Address: City & State: ZIP Code: Pharmacy: City: Cross Roads: INSURANCE INFORMATION

DEMOGRAPHIC FORM PATIENT INFORMATION. Mailing Address: City & State: ZIP Code: Pharmacy: City: Cross Roads: INSURANCE INFORMATION DEMOGRAPHIC FORM Today s date: Dr. Doug S. Clouse Dr. Benjamin MacQueen Dr. D. Gregory Stewart Name (Last, First, MI): Home phone no.: Cell phone no.: PATIENT INFORMATION Marital status (circle one) Single

More information

Cervical Spondylosis (Arthritis of the Neck)

Cervical Spondylosis (Arthritis of the Neck) Copyright 2009 American Academy of Orthopaedic Surgeons Cervical Spondylosis (Arthritis of the Neck) Neck pain is extremely common. It can be caused by many things, and is most often related to getting

More information

DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS

DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS Are you in the right place? Please read this before proceeding with paperwork: At Denver Chiropractic Center, we specialize in treating muscles with

More information

Orthopedic Initial Questionnaire. Date: Weight:

Orthopedic Initial Questionnaire. Date: Weight: Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete

More information

New England Pain Management Consultants At New England Baptist Hospital

New England Pain Management Consultants At New England Baptist Hospital New England Pain Management Consultants At New England Baptist Hospital Pain Management Center Health Assessment Dear New Pain Management Patient, Welcome to the New England Pain Management Consultants

More information

Orthopedic Initial Questionnaire

Orthopedic Initial Questionnaire Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete

More information

THE PHYSIO CENTRE. Motor Vehicle Accident. Instructions for Completing the Forms in this package

THE PHYSIO CENTRE. Motor Vehicle Accident. Instructions for Completing the Forms in this package THE PHYSIO CENTRE Motor Vehicle Accident Instructions for Completing the Forms in this package There are 2 forms enclosed in this package which are required for patients under MVA coverage. 1. Agree To

More information

Motor Vehicle Accident Information

Motor Vehicle Accident Information Motor Vehicle Accident Information Last Name: First Name: Social Security no.: DOB: Your Auto Insurance Company: Policy #: Policy Holder s Name: DOB: Accident Claim #: Adjuster s Name: Phone #: Ext. Attorney

More information

JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557

JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:

More information

MOTOR VEHICLE COLLISION/PERSONAL INJURY QUESTIONNAIRE

MOTOR VEHICLE COLLISION/PERSONAL INJURY QUESTIONNAIRE MOTOR VEHICLE COLLISION/PERSONAL INJURY QUESTIONNAIRE Please answer all questions completely: 1. Your name and address: 2. Phone Number: 3. In your own words, please describe the accident: 4. Where did

More information

Personal Injury Information. Nature of Accident

Personal Injury Information. Nature of Accident 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

More information

PATIENT INTAKE FORM Pennsylvania Chiropractic and Rehab, LLC Dr. Jason Cozart. OOB Age _

PATIENT INTAKE FORM Pennsylvania Chiropractic and Rehab, LLC Dr. Jason Cozart. OOB Age _ PATIENT INTAKE FORM Pennsylvania Chiropractic and Rehab, LLC Dr. Jason Cozart Patient Name: Date: OOB Age Address City, State, Zip Home Phone Work Phone Other em ail address M or F Marital --~------- Status

More information

Insurance (Let us make a copy of your insurance card and you can skip this section)

Insurance (Let us make a copy of your insurance card and you can skip this section) Today s Date: Name: What do you prefer to be called: Male / Female (please circle) Birth Date: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Email: Referred By: Employer: How long employed:

More information

Information on the Chiropractic Care of Lower Back Pain

Information on the Chiropractic Care of Lower Back Pain Chiropractic Care of Lower Back Pain Lower back pain is probably the most common condition seen the the Chiropractic office. Each month it is estimated that up to one third of persons experience some type

More information

Family First Chiropractic & Wellness Center 9430 Clairemont Mesa Blvd., Suite E San Diego, CA 92123

Family First Chiropractic & Wellness Center 9430 Clairemont Mesa Blvd., Suite E San Diego, CA 92123 PATIENT NAME: DATE: ADDRESS: CITY: STATE/ZIP CODE: HOME PHONE NUMBER: CELL PHONE NUMBER: SOCIAL SECURITY NUMBER: DATE OF BIRTH: AGE: GENDER: EMERGENCY CONTACT NAME: EMERGENCY CONTACT PHONE NUMBER: EMPLOYER

More information

PATIENT INSURANCE AUTHORIZATION WORKSHEET

PATIENT INSURANCE AUTHORIZATION WORKSHEET PATIENT INSURANCE AUTHORIZATION WORKSHEET We accept all insurances that have in-network and out-of-network benefits. If you do not have insurance benefits for physical therapy, please call us at 858-457-3545

More information

OAHU SPINE & REHAB Patient Information Form

OAHU SPINE & REHAB Patient Information Form Date: OAHU SPINE & REHAB Patient Information Form Pt. Number: First Name Last Name Date of Birth / / Address City State Zip Home Ph ( ) Work Ph ( ) Age Email Social Security # - - Sex: M / F Driver s License

More information

Danita Thomas Heagy, DC, LLC 4425 US 1 South, Suite 109 St Augustine FL 32086-3127 904-797-5100 www.drdanita.com

Danita Thomas Heagy, DC, LLC 4425 US 1 South, Suite 109 St Augustine FL 32086-3127 904-797-5100 www.drdanita.com WELCOME! Thank you for choosing this office to assist you with your health care. Once the exam is complete, I will present my findings and recommendations to you briefly. At the Health Dialogue, we will

More information

Cancellation/No Show Policy

Cancellation/No Show Policy Cancellation/No Show Policy If you are unable to keep your scheduled appointment we require a 24 hour advance notice. Failure to provide this notice will result in a $50.00 cancellation/no show fee. You

More information

PATIENT INFORMATION. Age: Street address: Email: Primary Phone no.: City: State: ZIP Code: P.O. box: Occupation: Employer: Employer phone no.

PATIENT INFORMATION. Age: Street address: Email: Primary Phone no.: City: State: ZIP Code: P.O. box: Occupation: Employer: Employer phone no. (Please Print) Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Birth date: Age: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Sex: M F Street address:

More information

INSURANCE INFORMATION FOR MOTOR VEHICLE ACCIDENT CLAIMS. Date of Accident- YYYY-MM-DD - - Your name -

INSURANCE INFORMATION FOR MOTOR VEHICLE ACCIDENT CLAIMS. Date of Accident- YYYY-MM-DD - - Your name - INSURANCE INFORMATION FOR MOTOR VEHICLE ACCIDENT CLAIMS Date of Accident- YYYY-MM-DD - - Your name - Name of car insurance company- Branch Location- Name of insurance adjuster- Telephone - Fax- - Name

More information

Name. Date of Birth Age Occupation. Chief Complaint Please describe your present complaint(s)

Name. Date of Birth Age Occupation. Chief Complaint Please describe your present complaint(s) Health History 15404 E Springfield Ave Suite 100 Spokane Valley, WA 99037 509.892-9800 Date / / Name Date of Birth Age Occupation Are you here because of: AUTO ACCIDENT? Y / N WORK INJURY? Y / N Chief

More information

7% - 1 /% % 1.14 0 "1,( (1,( 14 - "!#% #"!A(" "4:2 4!(!2"= B"!2 #!B! !("! B!!2"!!"!" -2!

7% - 1 /% % 1.14 0 1,( (1,( 14 - !#% #!A( 4:2 4!(!2= B!2 #!B! !(! B!!2!!! -2! 7% -!"!#$$ %&" '()* +,- *+$./- *+$#-*+$ 0 & - 1,-1./-1#-10!1121 1(1.31-2!21021(14 1 /% % 1.14 0 "1,( (1,( 14,35!,%#!61#1,(01141-1-"&-" 1-%11( -" 171.!153-2 -- "-8 -#1#&(19!1&&:1-! &(";!"./

More information

Notice of Independent Review Decision DESCRIPTION OF THE SERVICE OR SERVICES IN DISPUTE:

Notice of Independent Review Decision DESCRIPTION OF THE SERVICE OR SERVICES IN DISPUTE: Notice of Independent Review Decision DATE OF REVIEW: 08/15/08 IRO CASE #: NAME: DESCRIPTION OF THE SERVICE OR SERVICES IN DISPUTE: Determine the appropriateness of the previously denied request for physical

More information

Motor Vehicle Accident Insurance Information

Motor Vehicle Accident Insurance Information AUTOMOBILE ACCIDENT OFFICE POLICY If you have been injured or suspect you have been injured during an automobile accident you must tell your insurance company within seven days of the occurrence of a motor

More information

Auto Accident Injury Package New Patient Forms

Auto Accident Injury Package New Patient Forms Auto Accident Injury Package New Patient Forms The Following Individual Documents have been combined into ONE Auto Accident Injury Package of Downloadable PDF New Patient Forms. New Patient Forms Auto

More information

21031 Michigan Avenue Dearborn, MI 48124

21031 Michigan Avenue Dearborn, MI 48124 21031 Michigan Avenue Dearborn, MI 48124 19725 Allen Rd #102 Brownstown, MI 48134 44633 Joy Rd #200 Canton, MI 48187 Phone: 313-277-6700 FAX: 313-277-2483 Date: Dear Patient: An appointment has been scheduled

More information

PERSONAL INJURY QUESTIONNAIRE

PERSONAL INJURY QUESTIONNAIRE PERSONAL INJURY QUESTIONNAIRE NAME: PHONE: ( ) ADDRESS: CITY/STATE/ZIP: AGE: BIRTHDATE: SEX: SS # EMPLOYER'S NAME/ADDRESS: YOUR INSURANCE CO: POLICY #: AGENT'S NAME & PHONE: NAME ON POLICY (IF OTHER THAN

More information

SPINE PATIENT HISTORY FORM

SPINE PATIENT HISTORY FORM Trenton Orthopaedic Group 116 Washington Crossing Road 1225 Whitehorse-Mercerville Road Pennington, NJ 08534 Bldg. D., Suite 220 Mercerville, NJ 08619 22-1897695 SPINE PATIENT HISTORY FORM Please print

More information

O CONNOR REHAB & WELLNESS CLINIC. Patient Information Record

O CONNOR REHAB & WELLNESS CLINIC. Patient Information Record Patient Information Record Date: Patient s Name: Last First MI Address: Street City Province Postal Code Home Phone ( ) Work ( ) Cellular( ) (Please circle best number to reach you during the day) E-Mail

More information

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

Personal Information: Today s Date: Name: I prefer to be called: Address: Health Insurance Information: Do you have Health insurance? 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: Email: Social Security Number: Date of Birth: Height:

More information

PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date:

PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date: WORKERS COMPENSATION HISTORY PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date: Address: City: State: Zip:

More information

Welcome to Chirosports Coogee

Welcome to Chirosports Coogee PAGE 1 OF 6 Welcome to Chirosports Coogee At Chirosports our goal is to optimise your health and increase your quality of life. Chiropractic is an approach to health and wellbeing that assists the body

More information

The Effects of Cox Decompression Technic in the Treatment of Low Back Pain and Sciatica in a Golf Professional

The Effects of Cox Decompression Technic in the Treatment of Low Back Pain and Sciatica in a Golf Professional Cox Technic Email Case Report 72, June 2009, James Schantz DC 1 The Effects of Cox Decompression Technic in the Treatment of Low Back Pain and Sciatica in a Golf Professional James E. Schantz, D.C. Leading

More information

Pain Questionnaire. Center for Interventional Pain 1000 Health Center Drive, Suite 106 Mattoon, IL 61938 217-238-4495

Pain Questionnaire. Center for Interventional Pain 1000 Health Center Drive, Suite 106 Mattoon, IL 61938 217-238-4495 Center for Interventional Pain 1000 Health Center Drive, Suite 106 Mattoon, IL 61938 217-238-4495 Pain Questionnaire Date First name Last name Middle initial Date of birth Sex Male Female Height Weight

More information

Name, Today's Date Accident Date _

Name, Today's Date Accident Date _ Name, Today's Date Accident Date Please answer the following questions as accurately and honestly as possible. This fonn is very important and will aid your doctor in providing you the best ~ as well as

More information

WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called?

WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called? Today s Date: / / WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT Full Name: What would you prefer to be called? Street Address (If P. O. Box, provide street address

More information

INFORMATION FOR YOU. Lower Back Pain

INFORMATION FOR YOU. Lower Back Pain INFORMATION FOR YOU Lower Back Pain WHAT IS ACUTE LOWER BACK PAIN? Acute lower back pain is defined as low back pain present for up to six weeks. It may be experienced as aching, burning, stabbing, sharp

More information

TORREY PINES ORTHOPAEDIC MEDICAL GROUP Workers Compensation History Form. Date: Physician: Type of Evaluation: Patient: Height: Weight:

TORREY PINES ORTHOPAEDIC MEDICAL GROUP Workers Compensation History Form. Date: Physician: Type of Evaluation: Patient: Height: Weight: TORREY PINES ORTHOPAEDIC MEDICAL GROUP Workers Compensation History Form Date: Physician: Type of Evaluation: Patient: Height: Weight: Job Description Age: Right/Left handed: Employer at the time of injury:

More information

Herniated Disk. This reference summary explains herniated disks. It discusses symptoms and causes of the condition, as well as treatment options.

Herniated Disk. This reference summary explains herniated disks. It discusses symptoms and causes of the condition, as well as treatment options. Herniated Disk Introduction Your backbone, or spine, has 24 moveable vertebrae made of bone. Between the bones are soft disks filled with a jelly-like substance. These disks cushion the vertebrae and keep

More information

Auto Accident Questionnaire

Auto Accident Questionnaire Auto Accident Questionnaire Please complete all of the following questions regarding your accident. These details are very important, and the doctor will use them with his examination and final care plan.

More information

Cardiff and Vale Spinal Unit Mr M J H McCarthy FRCS

Cardiff and Vale Spinal Unit Mr M J H McCarthy FRCS Cardiff and Vale Spinal Unit Mr M J H McCarthy FRCS NECK / ARM PAIN QUESTIONNAIRE Affix Patient Label This document contains a series of standard assessments that are very useful in helping us assess your

More information