Cole Family Chiropractic 68 rth High Street, Ste E-106, New Albany, OH 43054 (614) 855-5454 (p) ~ (614) 283-5400 (f) WORKERS COMPENSATION HISTORY Patient Name: Employers Name: Telephone Number: Address: City: State: Zip: Carrier Name: Telephone Number: Address: City: State: Zip: Have you retained legal counsel for this injury? Yes If yes, give name and address: Injury Description Date present injury was received: Time of injury: A.M P.M. Overtime? Yes Who saw the accident? Name Who reported the accident? Name Title Title How did the injury occur? If working on a machine, give description: Do you use foot or hand levers? Yes Do you work overhead? Yes Do you have to reach? Yes Where? Movements on the job: Do you move to your: Right Left Up Down Under Over Do you pick up or lift? Yes If yes, how much? How often? From where to where? Do you lift from: Ground Bench Platform Box Pallet Other: (Please Describe) Do you lift in and out of a machine? Yes If working at a machine, do you? Sit Stand Kneel Is your work area cluttered? Yes If yes, with what? Is your work area: Oily Dirty Slippery Other In your job do you push or pull? Yes If yes, give specifics: Do you use a cart? Yes Two wheel Four wheel Type of wheels: Rubber Steel Plastic Condition of cart: Good Bad Other Number of carts being pushed or pulled at once: Total amount of weight being pushed or pulled on a daily basis:
Office Work If your injury has occurred from office work only, please fill out the following: I : Sit at desk Walk Stand Stoop Hold Carry Other Give percentage, if applicable: Do you operate office machinery? Yes If yes, what type? If your work is at a desk, give specifics of job, computer, typewriter, business machine, phone, etc. If walking, where to and job classification: Do you carry anything or pick anything up? Yes If yes, what? Previous Work History Give a job description of services or work performed for each job classification or source of employment for the preceding 10 (ten) years. 1. 2. 3. 4. 5. Was a pre employment exam performed or required? Yes If so: Date: Doctor: Place: Have you ever applied for Workers Compensation benefits before? Yes Date: Reason: Was there a time loss from work? Yes From: To: Year: State the degree of recovery: Did you retain legal counsel for these injuries? Yes If yes, give name and address: Present Work History What is the job classification of your normal job? Were you performing your normal job? Yes What shift were you working? How long have you been at your present job? Has there been a time of loss or absenteeism caused from job injury? Yes If yes, please explain: Average work week: Hours: Days:
Job Conditions Type of building: Type of floor: Rough Smooth Wood Concrete Steel Other: Type of windows: Open Closed windows Type of ventilation in the building: Blower A/C Heat Exhaust ne Other: Type of lighting in the building: Fluorescent Overhead On machine Other: Are you tired when you go home at night? Yes Do you have any outside jobs? Yes If yes, what type? Do you participate in any company sponsored programs such as exercise, sports, etc? Yes If yes, please describe: Type of shop: Union n Union Has outside help been hired? Yes If yes, why? How many employees are in the plant? How many employees per shift? How many employees do your job? What is the current injury ratio for that job? How many employees have been injured doing your job? Do you like your job? Yes If off work, do you want to return to your job? Yes What changes would you make in your job? The above information is accurate and has been completed to the best of my knowledge: Patient Signature Date Staff Signature Date
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FAMILY HEALTH HISTORY Patient Name Date Please review the below listed symptoms and conditions and indicate those that are current health problems of a family member by the designation C under his or her column. The designation P should be used to indicate a past problem. Leave blank those spaces that do not apply. If you require more space, use the reverse side of this form. Father Age Mother Age Spouse Age Brother(s) Age Age Sister(s) Age Age Children Age Age Age First Name Condition Allergies Anxiety Arthritis Auto Accidents Back Pain Cancer Constipation Diabetes Disc Problems Epilepsy Frequent Colds/Flus Gassy/Bloating Headache Heartburn Heart Trouble High Blood Pressure Low Energy Migraine Neck Pain Nervousness Pinched Nerve Scoliosis Sinus Trouble Sleeping Problems Other: Other: Other:
Patient Name: Cole Family Chiropractic 68 rth High Street, Ste. E-106 New Albany, OH 43054 (614) 855-5454 (p) ~ (614) 283-5400 (f) Terms of Acceptance Date: The goal of our office is to enable patients to gain control of their health. To attain this we believe communication is the key. There are often topics that are hard to understand and we hope this document will clarify those issues for you. Please read the below and if you have any questions please feel free to ask one of our staff members. Informed Consent: A patient, in coming to the chiropractic doctor, gives the doctor permission and authority to care for the patient in accordance with the chiropractic tests, diagnosis, and analysis. The chiropractic adjustment or other clinical procedures are usually beneficial and seldom cause any problems. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible to injury. The doctor, of course, will not give any treatment or care if he/she is aware that such care may be contra-indicated. Again, it is the responsibility of the patient to make it known, or to learn through healthcare procedures what he/she is suffering from: latent pathological defects, illnesses or deformities which would otherwise not come to the attention of the chiropractic physician. The chiropractic doctor provides a specialized, non-duplicating health care service. Your doctor of chiropractic is licensed in a special practice and is available to work with other types of providers in your health care regimen. I understand that if I am accepted as a patient by a physician at Cole Family Chiropractic, I am authorizing them to proceed with any treatment that they deem necessary. Furthermore, any risk involved, regarding chiropractic treatment, will be explained to me upon my request. Women Only: To the best of my knowledge I am / am NOT pregnant and (give my permission / don t give permission) to x-ray me for diagnostic interpretation. (Circle one above) (Circle one above) Missed Appointments: There is a possible fee charged for all appointments that are not canceled prior to scheduled visit. Consent to Evaluate and Treat a Minor: I, being the parent or legal guardian of, have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care. Communications: In the event that we would need to communicate your healthcare information, to whom may we do so? Spouse: Children: Others: one: May we leave messages regarding your personal healthcare information on any answering device, i.e. home answering machines or voicemails? Yes [ ] [ ] Acknowledgement I have read and fully understand the above statements. I have reviewed the notice of privacy practices (HIPAA) and have been provided an opportunity to discuss my right to privacy. Upon request I will be given a copy. Print Name: Signature: Date: