New Auto Patient Intake Form

Transcription

1 New Auto Patient Intake Form Patient Information Name Date of Birth Date Date of Accident Address City/State Zip Phone Address (for clinic news) Gender Marital Status #Children Occupation Company Name Work Phone Spouse/Gaurdian s Name Occupation Contact Name, In Case of Emergency Phone Your Auto Insurance Insurance Company_Policy# Insured s Name MedPay Claim # Adjustor s Name Phone# At-Fault Auto Insurance Insurance Company_Policy# Insured s NameClaim # Adjustor s Name Phone# Assignment of Benefits Release of Records I authorize my primary auto insurance company or tertiary auto insurance company to make payments to Denver Chiropractic, LLC for all services provided by Denver Chiropractic, LLC. I give permission for my doctors and any holder of my medical records to be released by Denver Chiropractic, LLC. I will provide all information needed to process my claims in a timely manner. Signature

2 History of Accident 1. Location of Accident City/State Street/s 2. Approx. Time of Day Weather Conditions? Seat Belt On? 3. Any Passengers? Names 4. Year/Make/Model of Your Vehicle Other Vehicle 5. Your Approx. Speed at Impact? Other Vehicle 6. Your Head Position at Impact?(turned L/R, up/down) You Aware of Impending Impact? 7. Drivers Feet Position at Impact? (brake, clutch, both, gas, etc.) 7. Witness Names? Photographs Taken? 8. What Part of Your Car Was Damaged? Their s 9. Description of the Accident 10. Diagram of the accident N W E 11. Cost of Repairing Your Car S 12. Did either insurance company refer you to the place where you got the estimate? 13. Were you paid for the vehicle damage? How much?

3 History of Accident Cont. 14. Did the Police Arrive? Which Police Department? 15. Police Officer s Name Was Anyone Cited? 16. Statements made by you or others at the scene 17. Have you made statements to any insurance company or anyone else? 18. Were any vehicles towed away from the scene? Which Vehicle? 19. Name of Other Driver Phone# 20. Date of Birth Was This a Company Vehicle? Which? 21. Drivers License # Vechile License # 22. Driver s Address 23. Damage to the other drivers car? Describe 24. Do you believe that any of the following were defective and resulted in either the accident itself or a worsening of your injuries? (road signs, roads, traffic signal, brakes, seat belt, airbags, seat,etc.) Injuries,Impairments, & Damages Injuries, impairments as a result of your accident?

4 Injuries,Impairments, & Damages Cont. Which of the following do you suffer from now, which you did not prior to the accident: Headaches Dizziness Difficulty Concentrating Long Term Memory Loss Short Term Memory Loss Amnesia Loss of Consciousness at Scene Blackouts Since Collision Forgetting ATM or other Numbers Reading Problems Writing Problems Typing Problems Apathy Irritability Sleep Disturbances Personality Changes Emotional Difficulties Relationship Difficulties Blurred Vision Photophobia (Sensitivity to Light) Vision Changes Intolerance to Alcohol Intolerance to Heat Intolerance to Cold Impaired Comprehension Impaired Learning Attention Impairment Loss of Libido Missing Periods of Time Speech Difficulties Concussion in Collision Nausea Vomiting Extreme Thirst Since Collision Fatigue Menstrual Irregularities Tinnitus (Ringing of Ears) Noise Intolerance Loss of Coordination Bumping Into Objects in View Loss of Balance Fluid in Ears Hearing Loss Vertigo (Spinning Sensation) Increased Symptoms in Crowds Anxiety Depression Change in Personality Flashbacks to Accident Scene Intrusive Thoughts of Accident Nightmares Since Collision Unusual Behavior Since Collision Social Withdrawal Panic Attacks Thoughts of Death /Suicide Weight Loss / Gain lbs Loss of Taste / Smell Blackouts with Neck Movements Dizziness with Neck Movements Clunk Sound w/ Moving Neck Jaw Pain Clicking in Jaw Pain with Chewing Numbness / tingling / weakness in arms? Yes No R L Level(s) Numbness / tingling / weakness in legs? Yes No R L Level(s) Did the Seatbelt bruise you? Where?

5 Injuries,Impairments, & Damages Cont. Where was headrest located before impact? Upper Back Mid Neck Mid Head Upper Head None Did your head or body strike anything inside the car? Yes No If so, what? Did you lose consciousness? Yes No Did items in the car get displaced?what? Did your Airbag(s) Deploy? Yes No Did your seats break? Yes No Ambulance Companies: Company Date From To Emergency Room, Hospitalizations, Outpatient Surgeries (Related only to this Collision): Physician Facility When Problems Treating Physicians / Specialists / Therapists (Related only to this Collision): Provider Facility Address Phone What are you not able to do anymore as a result of this accident?

6 Impaired Activities Injuries,Impairments, & Damages Cont. Circle all activities which have been impaired in any way by the accident in question: Daily Activities bathing/showering bending brushing teeth Dressing driving car vacationing dining out movie going standing sitting religious activities (bending/kneeling) sexual relations lifting church events child care shampooing hair eating Moving reading shaving shopping watching TV sleeping traveling social events Domestic Activities (Activities within the Home) Bending Cooking ironing housecleaning laundry Washing Dishes vacuuming dusting interior painting decorating Household Activities (Activities outside the Home) Trimming bushes Gardening Tree trimming Mowing Lawn Yard Work Exterior painting Car Washing Landcaping House Maintenence Farm activities Work Activities Sitting standing lifting using telephone computer work Reading bending typing writing child care Hobby Activities Aerobic exercise archery backpacking bowling badminton baseball basketball basketry bicycling Boxing card playing camping dancing fencing Fishing flying football gardening golf Handball gymnastics health clubs hockey hunting Judo horseback riding ice skating Karate painting Yoga jogging/running photography raquetball rafting sailing mountain climbing sewing snow skiing swimming walking musical instruments volleyball water skiing water sports weight lifting Activities which you have performed despite pain, due to financial, family or personal needs (Duties Under Duress): Work Education Domestic (Activities within the Home) Household (Duties outside the Home) Past Motor Vehicle Accidents, Workers Compensation Claims, or other claims of Any Sort:

7 Please describe your auto related injuries, list the worst injury first and the least impairing injury last. List Injury in Order of Importance Is the pain constant?(y/n). If not, Rate with 0 to 10 scale (10 being the worst) the Describe what the pain feels Getting Worse(i.e. neck, left shoulder, headache). what % of the day does it affect you. least amount pain, avg. pain, and max pain level. like (achy, stabbing, etc.) or better? Condition # What Makes it Worse?(dishes, getting dressed, driving, etc.) What Makes it Better?(stretching, not moving, heat, pills, etc.) Shade the injured areas List Allergies List Current Presciptions Current Over The CounterMedications

8 Past Medical History Personal Physician (Name) Phone: Address: Please list all other past doctors or other health care providers (medical and alternative) you have seen and include their addresses, the dates or time periods in which you saw them, the reasons for seeing them, the types of treatment given to you, and whether they might have any information that would help us compare your present health with your health before the collision. (Excluding those noted above.) List, as carefully and accurately as you can, all injuries, illnesses, or medical conditions you have had in your life, even if they have no similarity to the injuries that you received in this collision. Include the approximate dates, the cause of the injuries, the doctors who treated you, and whether you fully recovered from these problems. If any lawsuit or claim was made for any of those injuries please so state. Family Health History (circle any that apply) auto-immune, spine problems, arthritis, cancer, diabetes, heart disease, kidney disease, metal disorder, bleeding disorder, seizures.

9 Consent to Examination & Treatment I hereby request and consent to the performance of chiropractic examinations, adjustments, dry needling, graston technique, active release technique, flexion-distraction therapy, moist heat, electrotherapy, ultrasound, kinesio taping, and other procedures on me (or the patient named below, for whom I am legally responsible) by the licensed doctors at Denver Chiropractic, LLC. I understand and I am informed that, in the practice of chiropractic that there are some risks to examination and treatment including, but not limited to, soreness, fractures, disc injuries, strokes, dislocations, sprains, pneumothorax, increased symptoms, or no improvement. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known, is in my best interest. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatments. I intend this consent form to cover the entire course of treatment of my present condition and for any future conditions for which I seek treatment. I understand that I may refuse treatment at any time and that I am responsible for my healthcare choices Our Privacy Policy The office of Denver Chiropractic, LLC is committed to upholding the security and confidentiality of personal information that you provide to us. We take our responsibility of safeguarding your information very seriously. We do not share or sell patient information with anyone outside our office without your written consent. This policy covers information including personal, financial, or health information about a consumer or customer relationship. I hereby authorize that my records of evaluation and treatment with the office of Denver Chiropractic, LLC may be forwarded to referring physicians, specialists, or therapists who are also involved in my healthcare. Regarding Your Healing 1. Auto injuries produce wide spread damage and thus take more visits then an average case of non-auto related acute neck or back pain. On average, a typical whiplash injury will require approximately 26 visits for resolution of the injuries. Everyone responds to treatment slightly different which may shorten or lengthen the amount of total visits needed. 2. Neck or back pain usually fluctuates, meaning that you will have flare ups along the course of your healing. It is expected to have aggravations of your injuries. 3. If you have never been adjusted you may be sore after your treatment. This soreness is similar to a long hike or a good workout type of soreness. Soreness can be a good response, as is the soreness you get after a good workout. I understand and have read the consent to treatment and examination, our privacy policy, and information regarding your healing. Signature Date

10 Neck Disability Index Pain Intensity (Circle One) A. I have no pain at the moment. B. The pain is very mild at the moment. C. The pain is very moderate at the moment. D. The pain is fairly severe at the moment. E. The pain is very severe at the moment. F. The pain is the worst imaginable at the moment. Personal Care- Washing, Dressing etc (Circle one) A. I can look after myself normally, without causing extra pain. B. I can look after myself normally, but it causes extra pain. C. It is painful to look after myself, but I am slow and careful. D. I need some help but manage most of my care. E. I need help everyday with every aspect of my self-care. F. I do not get dressed, I wash with difficulty and I stay in bed. Lifting (Circle One) A. I can lift heavy weights without extra pain. B. I can lift heavy weights, but it causes extra pain. C. Pain prevents me from lifting heavy weights off the floor, but can lift if they are conveniently positioned such as a table. D. Pain prevents me from lifting heavy weights but I can manage light/medium weights if they are conveniently positioned. E. I can only lift light weights. F. Pain prevents me from lifting weight from the floor. Reading (Circle One) A. I can read as much as I want to with no pain in my neck. B. I can read as much as I want to with slight pain in my neck. C. I can read as much as I want with moderate pain in my neck. D. I can t read as much as I want because of the moderate pain in my neck. E. I can hardly read at all because of the severe pain in my neck. F. I cannot read at all. Headaches (Circle one) A. I have no headaches at all. B. I have slight headaches, which come in-frequently. C. I have moderate headaches, which come in-frequently. D. I have moderate headaches, which come frequently. E. I have severe headaches, which come frequently F. I have headaches almost all the time. Date Concentration (Circle One) A. I can concentrate fully when I want to with no difficulty. B. I can concentrate fully when I want to with slight difficulty. C. I have a fair amount of difficulty when concentrating. D. I have a lot of difficulty in concentrating when I want to. E. I have a great deal of difficulty in concentrating when I want to. F. I cannot concentrate at all. Work (Circle one) A. I can do as much work as I want to. B. I can only do my usual work, but no more. C. I can do most of my usual work, but no more. D. I cannot do my usual work. E. I can hardly do any work at all. F. I can t do any work at all. Driving (Circle one) A. I can drive my car without any neck pain. B. I can drive my car as long as I want with slight neck pain. C. I can drive my car as long as I want with moderate neck pain. D. I can t drive my car as long as I want because of moderate pain in my neck. E. I can hardly drive at all because of severe pain in my neck. F. I can t drive my car at all. Sleeping (Circle one) A. I have no trouble sleeping. B. My sleep is slightly disturbed. C. My sleep is mildly disturbed (1-2 hours sleepless). D. My sleep is greatly disturbed (2-3 hours sleepless). E. My sleep is greatly disturbed (3-5 hours sleepless). F. My sleep is completely disturbed (5-7 hours sleepless). Recreation (Circle one) A. I am able to engage in all of my recreation activities with no neck pain at all. B. I am able to engage in all of my recreational activities, with some neck pain. C. I am able to engage in most, but not all of my usual activities because of neck pain. D. I am able to engage in a few of my activities because of pain in my neck. E. I can hardly do any of my recreational activities because of pain in my neck. F. I can t do any recreation activities at all.

11 Low Back Disability Index Pain Intensity (Circle one) A. The pain comes and goes and is very mild. B. The pain is mild and does not vary much. C. The pain comes and goes and is moderate. D. The pain is moderate and does not vary much. E. The pain is severe but comes and goes. F. The pain is severe and does not vary much. Personal Care (Circle one) A. I would not have to change my way of washing or dressing in order to avoid pain. B. I do not normally change my way of washing or dressing even though it causes some pain. C. Washing and dressing increase the pain, but I manage not to change my way of doing it. D. Washing and dressing increase the pain and I it necessary to change my way of doing it. E. Because of the pain, I am unable to do any washing and dressing without help. F. Because of the pain, I am unable to do any washing or dressing without help. Lifting (Circle one) A. I can lift heavy weights without extra pain. B. I can lift heavy weights, but it causes extra pain. C. Pain prevents me from lifting heavy weights off the floor. D. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, e.g. on the table. E. Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. F. I can only lift very light weights, at the most. Walking (Circle one) A. Pain does not prevent me from walking any distance. B. I have some pain with walking but it does not increase with distance. C. Pain prevents me from walking more than one mile. D. Pain prevents me from walking more than 1/2 mile. E. I can only walk while using a cane or on crutches. F. I am in bed most of the time and have to crawl to the toilet Sitting (Circle one) A. I can sit in any chair as long as I like without pain. B. I can only sit in my favorite chair as long as I like. C. Pain prevents me from sitting more than one hour. D. Pain prevents me from sitting more than 1/2 hour. E. Pain prevents me from sitting more than ten minutes. F. Pain prevents me from sitting at all Standing (Circle one) Date A. I can stand as long as I want without pain. B. I have some pain while standing, but it does not increase with time. C. I cannot stand for longer than one hour without increasing pain. D. I cannot stand for longer than 1/2 hour without increasing pain. E. I can't stand for more than 10 minutes without increasing pain. F. I avoid standing because it increases pain right away Sleeping (Circle one) A. I get no pain in bed. B. I get pain in bed, but it does not prevent me from sleeping. C. Because of pain, my normal night's sleep is reduced by less than one-quarter. D. Because of pain, my normal night's sleep is reduced by less than one-half. E. Because of pain, my normal night's sleep is reduced by less than three-quarters. F. Pain prevents me from sleeping at all. Social Life (Circle one) A. My social life is normal and gives me no pain. B. My social life is normal, but increases the degree of my pain. C. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc. D. Pain has restricted my social life and I do not go out very often. E. Pain has restricted my social, life to my home. F. Pain prevents me from social, life at all. Traveling (Circle one) A. I get no pain while traveling. B. I get some pain while traveling, but none of my usual forms of travel make it any worse. C. I get extra pain while traveling, but it does not compel me to seek alternative forms of travel. D. I get extra pain while traveling which compels me to seek alternative forms of travel. E. Pain restricts all forms of travel. F. Pain prevents all forms of travel except that done lying down. Changing Degree of Pain (Circle one) A. My pain is rapidly getting better. B. My pain fluctuates, but overall is definitely getting better. C. My pain seems to be getting better, but improvement is slow at present. D. My pain is neither getting better nor worse. E. My pain is gradually worsening. F. My pain is rapidly worsening.

12 Provider Lien TO: Denver Chiropractic, LLC FROM: (Print Patient Name) I hereby authorize and direct my attorney/tertiary insurance company, to pay directly to said health provider such sums as may be due and owing it for medical services rendered me by reason of my accident on (date of accident) and to withhold such sums from the net proceeds of any settlement, judgment or verdict as may be necessary to adequately protect said health provider. Net proceeds means the gross amount recovered, less any attorney fees and costs. In exchange for receiving this lien, said health provider agrees to forego further collection efforts. I hereby further give a lien on my case to said health provider against any and all net proceeds of 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 further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee. This lien shall be irrevocable and shall be valid and enforceable out of the net proceeds of my settlement, judgment or verdict. I understand that if I discharge my attorney, I have an obligation to notify said health care provider in writing within 48 hours. Please initial all statements below: I understand that I will be charged the full usual and customary prices for my medical care and not cash pay or insurance rates. I further understand that this is the amount I am expected to repay the provider. I further agree that this amount is reasonable. I agree that if, at any time, including prior to settlement, the provider finds it necessary to proceed against the patient to collect medical bills, the provider may do so. In the event of the receipt of funds and non-payment resulting in the institution of lien enforcement proceedings, I shall be responsible for the payment of all reasonable fees and costs, including attorney s fees incurred by my medical providers in enforcing said lien. I fully understand that I am directly and fully responsible to said health provider for all medical bills submitted for services rendered me and that this agreement is made solely for said health provider s additional protection and in consideration of awaiting payment. Date [PATIENT NAME] We, the health provider, agree to the terms stated above. By: Denver Chiropractic, LLC / Owner: Dr. Trent Artichoker Date