Work-Injury History Office of Dr. Scott F. Gillman, Date: File: Pg.1/3
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- Clarence Bryan
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1 Work-Injury History Office of Dr. Scott F. Gillman, Date: File: Pg.1/3 Full Name (Nick Name: ) Age: Marital Status: M S W D Children? (#, ages): Date of Injury: Who is your Primary Care Physician? Occupation: Are you: right handed left handed ambidextrous Describe (briefly) how you were hurt while at work: Circle, Check, or In Any Way Describe Your Answers: Any poor work-site conditions (e.g. wet floor, poor lighting)? No Yes: Did you experience any pain or other symptoms immediately after the incident? No Yes Where: Did any pain occur later or next day? No Yes How so? Where did you go after the accident: Home Back to Work Hospital (by ambulance, friend, co-worker, family) Not including the hospital, have you seen any healthcare providers prior to your visit here? No Yes Please list them, e,g, PT s, MD s, LMT s, etc: Have you had MRI, CT scan, X-Rays? No Yes : When/Where? Was pain medicine prescribed? No Yes If yes, by which doctor? Any braces, supports, or canes issued? No Yes Are pain(s)/symptom(s): Improving Getting Worse Changing in Character or Location The Same Ever had similar pain/symptoms/problems in the involved areas before? No Yes Please Describe: Ever been to a chiropractor? No Yes When & Why?: Any previous vehicle crashes? No Yes When? Any previous work-related injury? No Yes When? List all dates (times) you missed from work due to this injury: Are you currently working limited hours? No Yes Working light or limited duty? No Yes Did you have any work limitations or disabilities prior to the work-accident? No Yes
2 Using the diagram below, circle or mark the where you feel pain, aching, numbness/tingling, or any other symptom. Right Left Left Right Describe Each Problem or Painful Body Region Separately (as best you can, e.g. "headaches,"or "lower back,"or "knee"). Pain or Problem Area #1: Are symptoms?: Constant Comes & Goes; Grade your pain from 0 (no pain) to 10 (unbearable): What provokes or alleviates your symptoms? Pain or Problem Area #2: Are symptoms?: Constant Comes & Goes; Grade your pain from 0 (no pain) to 10 (unbearable): What provokes or alleviates your symptoms? Pain or Problem Area #3: Are symptoms?: Constant Comes & Goes; Grade your pain from 0 (no pain) to 10 (unbearable): What provokes or alleviates your symptoms? Pg. 2 of 3; WC- History Form; Office of Dr. Scott F. Gillman ( )
3 Past Medical History: Check the box for any condition for which in the past - you ve been medically treated for, been diagnosed with, or had significant medical problems. Back Pain Concussion Irritable Bowel HIV + Nervousness Neck Pain Struck Unconscious Digestion Problems Hepatitis Depression Numbness/Tingling Eye Injuries Heart Problem Mononucleosis Anxiety Sciatica Sinus Problems Kidney Problem Anemia Chemical Addiction Jaw Pain/TMJ Shortness of Breath Thyroid Problem Excessive Thirst Eating Disorder Headaches Dizziness Liver Problem Night Sweats Allergies Shoulder Chest Pains Gall Bladder Problem Weight Loss Difficulty Breathing Elbow/Arm High Blood Pressure Lung Disease Frequent Urination Asthma Carpal Tunnel Syn. Arteriosclerosis Menstrual Irregularity Diabetes Chronic Cough Knee Problems Constipation Menstrual Cramps Limb Edema Cancer Foot or Ankle Sleep Disorder Prostate Problem Bruise Easily Lumps or Tumors Tendonitis/Bursitis Fractures Uterus/Ovary Prob s Chronic Fatigue Other: Sprained Ankle(s) Osteoporosis ('penia) Skin Diseases Lymes Disease Other: List all surgeries, any major injuries or any hospitalizations you had in the past. Do you have any residual issues? List all medicines, herbs/vitamins you currently take (attach or a list if you prefer); Social History: Family Medical History: Diabetes, Heart Ds., Arthritis, Cancer Do you smoke? No Yes How much? Consume alcohol? Daily Weekly Seldom Never Father: Do you eat fast food? Daily Weekly Seldom Never Mother: Caffeine Beverages/Day Seldom/Never Siblings: Do you have a regular exercise program? No Yes If yes, what and how often? List any hobbies or sports you participate in: Were you very active in any particular sports when you were younger (e.g. high school track, college football)? Patient Signature: Date: Pg. 3 of 3; WC-History Form; Office of Dr. Scott F. Gillman ( )
4 PATIENT INFORMED CONSENT TO TREATMENT The Nature Of Chiropractic Treatment: The doctor will use his hands or mechanical devices in order to move your joints and mobilize soft tissues (e.g. muscles, ligaments). A crack or pop sound is inherent in some of the joint manipulation procedures and is a natural effect of joint movement. Various other procedures, including, but not limited to, hot packs, electric stimulation, therapeutic ultrasound, exercises, massage or other soft tissue therapies may also be used. Physical examination is physical! It involves the doctor manually challenging your joints and testing your muscle strengths and it can sometimes lead to temporary soreness or worsening of your pain. Possible Risks and Side Effects: As soon as ANY doctor intervenes with your healthcare there is risk of side effects and complications. The risk of serious complications from chiropractic treatment has been described as extremely rare. While less serious complications are possible from chiropractic treatment, most are highly unlikely, but could include fractures, sprains/strains, injury to intervertebral discs, nerves, spinal cord, a worsening of symptoms or development of new symptoms. Cerebrovascular accident such as a stroke is highly sensationalized by the news media, but real research data proves that it is very rare, with odds calculated as one in a million to one in forty million, about the same odds of a stroke from having your hair washed in a salon ( beauty parlor syndrome ), and significantly less than the odds of being struck by lightning. Usually, side effects of treatment include transient muscular stiffness or soreness. Some people report it as feeling like they exercised new muscles for the first time. Some procedures (e.g. hot packs or deep tissue massage) could produce skin irritation, burns or bruises. Other Treatment Options That Could Be Considered (Just To Put Things In Perspective): Over-the-counter analgesics, prescription medicines, surgical procedures, and hospitalization all carry significant risk of complications, far greater than those encountered in a chiropractic office. Risks Of Remaining Untreated: While it is possible that your symptoms can go away with no treatment at all, delay of treatment could reduce body mobility, induce chronic pain, and lessen chances of complete recovery. I have read the explanation above regarding chiropractic treatment. I have had the opportunity to have questions answered to my satisfaction. I freely decided to undergo the recommended treatment, and hereby give full consent to treatment. Patient or Parent/Guardian Date Witness
5 OFFICE POLICIES OF THE GILLMAN CHIROPRACTIC OFFICE PERMISSION TO COMMUNICATE (HIPPA) I authorize and give permission to Dr. Scott F. Gillman and his staff and/or associates to communicate with me by regular mail, , phone calls to my home, work, wireless phone, or answering machine(s). I understand that communication will be in regards to appointments, clerical issues and clinical issues. I understand that due diligence will be employed in being discrete about any clinical issues conveyed via the above modes of communication. I understand that I have the right to refuse certain types of communication by notifying Dr. Scott F. Gillman or his staff in writing. AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION (HIPPA) I hereby authorize Dr. Scott F. Gillman or his assigned staff members to release information contained in my medical record to any and all insurance carriers from whom I may be due benefits, to my primary care physician or other healthcare providers associated with my treatment, to the state chiropractic society in the event their assistance is needed on my behalf, and to my attorney of record (if an attorney is involved). ASSIGNMENT OF PROCEEDS Under Massachusetts Law, Chapter 106, Section 9-109(C)(8) and 9-315(C), I hereby instruct and direct that payments for my services be sent directly to Dr. Scott F. Gillman or the Gillman Chiropractic Office and not to me, my guardians, my estate, or my attorney, regardless of any assignment of benefits my attorney or others may present on my behalf, and regardless of the date such other assignment or instruction may be signed by me or presented by others. I hereby instruct and direct that payments for health care provided me by Dr. Scott F. Gillman, as reflected in bills for such service that he may present, as may be due me under terms of a contract of health insurance, or as a result of an action at court, settlement, structured settlement, judgment, verdict or arbitration award which I may receive or be due, be sent directly to Dr. Scott F. Gillman. This instruction shall be considered irrevocable, and shall survive me, and my period of care under Dr. Gillman forever and without exception. Regarding only payment for Dr. Gillman s services to me as reflected in bills he presents I hereby rescind any and all assignments of benefit presented by my attorney of any date prior to this date to any party receiving this notice. Also, under all circumstances, I direct and instruct that any monies sent to any party as payment for the services at the Gillman Chiropractic Office, following receipt of office bills and or statements, BE MADE PAYABLE SOLELY TO DR. GILLMAN. COLLECTION POLICY AGREEMENT I hereby acknowledge that I am ultimately fully responsible for the payment of all charges or fees for services provided me regardless of any contract of insurance, any action at court, any settlement, structured settlement, judgment, verdict or arbitration award which I may receive or be due, or the course or outcome of any dispute regarding same. I also understand that I may be charged a 1.5% monthly interest charge for any patient balances unpaid after 30 days. I agree to deliver to Dr. Gillman any check, draft or funds that I receive from any source intended as payment for services rendered me by Dr. Gillman within 10 calendar days of receipt by me and to be responsible for 1.5% month interest accrued for failure to deliver money after 30 days. I agree to reimburse Dr. Gillman for all reasonable collection costs he incurs that arise from collection actions he takes against me in the process of settling my account. APPOINTMENT POLICY We reserve the right to charge a $30 fee for appointments that are blatantly missed or appointments that are cancelled without notice of at least four (4) hours. The $30 fee is your bill, not your insurance company s bill. I acknowledge that I received these HIPAA and office policies and have read, understood and agreed to them per my signature: Signature: Date: Dr. Scott F. Gillman Chiropractic & Sports Medicine 251 W. Central Street, Natick, MA (Phone) (Fax)
6 AGREEMENT TO PAY COSTS IN THE EVENT OF WORKERS COMPENSATION CLAIM DENIAL Claimant Name: Address: Employer: Address: Workers Comp. Ins. Carrier: Date of Injury: Claim Number: If it is determined by the worker s compensation board that the above-named claim is not a result of a compensable workers compensation case, I hereby agree to pay Dr. Scott F. Gillman of 251 West Central Street, Natick MA the usual and customary fees for services rendered. Patient Signature Date Dr. Scott F. Gillman Chiropractic & Sports Medicine 251 W. Central Street, Natick, MA (Phone) (Fax)
7 WORKERS COMPENSATION POLICY If you have been involved in an on-the-job injury you are entitled to receive medical/chiropractic treatment. The injured party, in most instances, is allowed freedom of choice in selection of a doctor. To activate you claim you must do the following: 1. Report you injury and complete an accident report and have it on record with your employer. 2. Furnish this office with all the pertinent information that relates to the accident. Specifically: a. Provide this office with the name, address, contact person and phone number or your employer. b. Provide this office with the name, address, contact person, phone number and claim number of your employer s worker s compensation insurance carrier. c. If you seek legal counsel, please provide this office with the name, address, contact person and phone number. Failure to complete the above steps can result in your being personally responsible for the payment of services rendered by this office. The worker s compensation carrier will be notified of your treatment plan with our office and will be billed directly. Payment for services rendered will be paid directly to this office. If the carrier denies your claim or refuses to pay your bill, it will become your responsibility to make payment. Charges for missed appointments will not be billed to the insurance carrier and are your responsibility with this office. I have read and understand the above policy. Patient Signature Date
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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
***************PATIENT INFORMATION****************
SEP BADY, MD ***************PATIENT INFORMATION**************** TODAYS DATE: / / WHICH DOCTOR ARE YOU SEEING? BADY KURUVILLA LIU OTTEN TRAINOR YEE PATIENT LAST NAME: FIRST: MIDDLE INITIAL: ADDRESS: CITY/STATE:
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
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
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.
DATE NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.0019 Joseph M. Phillips, M.D., Ph.D. Board Certified in Pain
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
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
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
PATIENT INFORMATION FORM
737 Pearl Street, Suite 108 Phone: 858.456.2114 Fax: 858.456.2103 www.abilityrehabsd.com PATIENT INFORMATION FORM Please print and complete ALL items. If an item doesn t apply, put N/A Patient Name: Age:
OUR FINANCIAL POLICY & HOW IT WORKS FOR YOU
OUR FINANCIAL POLICY & HOW IT WORKS FOR YOU OUR RESPONSIBILITIES We will: verify your benefits. bill your insurance at your request. provide guidance to minimize your insurance s denial of benefits/charges.
CHILDREN S PERSONAL INJURY/AUTO ACCIDENT
CHILDREN S PERSONAL INJURY/AUTO ACCIDENT Child s Name: Birth Date: Age: Sex: M F Lives with Both Parents Mother Father Referral/How did you hear about us? Mother s Name: Email Address: Home Phone: Cell
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
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(
How To Get A Medical Checkup From A Doctor
Welcome to Schoonman Chiropractic. We look forward to providing you the best possible care. Please fill out the following information for our records: Name: Name of Parent (If Minor): Address: Phone Number:
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
Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,
Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia
Hands-On Care Physical Therapy P.C PhysioCare Physical Therapy P.C EXPLANATION OF PROCEDURES
EXPLANATION OF PROCEDURES Welcome to our practice. You are here because you have been referred to us by your doctor for Physical Therapy. Physical Therapy is defined as: The evaluation, treatment or prevention
New Patient Registration Information
New Patient Registration Information ADAMS COUNTY LOCATIONS YORK COUNTY LOCATIONS Adams Health Center........ (717) 339-2620 Apple Hill................ (717) 741-8240 Aspers Health Center........ (717)
EASTERN CONNECTICUT REHABILITATION CENTERS PHYSICAL THERAPY INFORMATION PACKET
EASTERN CONNECTICUT REHABILITATION CENTERS PHYSICAL THERAPY INFORMATION PACKET THANK YOU FOR CHOOSING ECRC-PT THIS PACKET INCLUDES IMPORTANT INFORMATION TO ASSIST IN YOUR RECOVERY AND UNDERSTANDING ABOUT
FAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
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
Dallas Neurosurgical and Spine Associates, P.A Patient Health History
Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of
Motor Vehicle Accident Intake Form
2100 SE Lake Rd Ste 1 Milwaukie OR 97222 Motor Vehicle Accident Intake Form Today's Date: About You Name: Gender: Male Female Address: City: State: Zip: Home Number: Work Number: Other Number: Email Address:
Thank you for making an appointment with our office. We look forward to serving your visual needs.
Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax
460 Main St, East. Unit M3 Hamilton, ON L8N 1K4 T: 905 524 3709 F: 905 524 4866 info@physiotherapyclinic.ca
Page 1 of 6 Date Patient Information (Please complete all fields below) Last Name First Name Intl. Street Address Home Tel. City/Town Province Postal Code Work Tel. Date of Birth (mm/dd/yyyy) Gender M
AON Physical Therapy & Wellness
AON Physical Therapy & Wellness PATIENT REGISTRATION Patients First and Last Name Intake Taken By- Appointment Date / Therapist Date- Date of Birth: Is the patient Under 18? If so, who is the guarantor?
WELCOME PATIENT CONDITION
NATURAL CARE WELLNESS CENTER 6 SEELEY LANE, ELIOT, ME 03903 WELCOME PATIENT CONDITION PATIENT INFORMATION Date Reason for Visit SS# Patient Name Last Name First Name Middle Initial Address Do you suffer
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