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Auto Injury Patient Intake

Auto Injury Patient Intake Form

PATIENT APPLICATION SURVEY
Today's Date*
MM
DD
YYYY
Patient Name*
First Last
Patient Birth Date*
Date Format: MM slash DD slash YYYY
Patient Age*
Patient Gender*
- Male
- Female
Patient Marital Status*
- Single
- Married
- Divorced
- Widowed
Patient Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone*
Work Phone
Cell Phone
Email*
Occupation*
Emergency Contact Name*
First Last
Emergency Contact Phone 1*
Emergency Contact Phone 2
Emergency Contact Employer
How were you referred to our office?*
AUTO INJURY QUESTIONNAIRE
Your Auto Insurance Company*
Name on Policy*
At-Fault Auto Insurance Company*
Claim#*
At-Fault Auto Insurance Phone Number*
Fax#
(optional)
Do you have an attorney?*
- Yes
- No
Attorney Name
Attorney Address
Street Address City State ZIP Code
Attorney Phone Number
Date of Accident*
Date Format: MM slash DD slash YYYY
Time of Day*

: HH

MM
Were you:*
- Driver
- Passenger
- Back Seat Driver Side
- Back Seat Passenger Side
Number of people in the vehicle:*
Please enter a number greater than or equal to 1.
Were you wearing a seat belt?*
- Yes
- No
Were you struck from:*
- Behind
- Front
- Driver Side
- Passenger Side
Speed of your car:*
Speed of the other car:*
Were you knocked unconscious?*
- Yes
- No
How long were you unconscious?
Were police notified of the accident?*
- Yes
- No
What is the make of your car?*
Example: Toyota, Honda, Ford...
What is the model of your vehicle?*
Example: Camry, CR-V, F-150....
What year is your vehicle?*
How much damage was done to your vehicle?*
Enter '0' if you are unsure of a dollar amount.
In your own words, please describe the accident:*
Did you have any physical complaints BEFORE THE ACCIDENT?*
- Yes
- No
Please describe:
Describe how you felt during the accident:*
Describe how you felt immediately after the accident:*
Describe how you felt later that day, after the accident:*
Where were you taken after the accident?*
What type of treatment did you receive after the accident?*
What other doctors have treated you since the accident?*
Since the accident, are your symptoms:*
- Improving
- Getting Worse
- Same
Have you lost time from work as a result of this accident?*
- Yes
- No
Please explain lost time from work:
Have you noticed any activity restrictions as a result of the accident?*
- Yes
- No
Please explain activity restrictions:
PURPOSE OF THIS VISIT
Reason for this visit - Main Complaint*
Is this purpose related to an auto accident or work injury?*
- Yes
- No
When did the accident or injury occur?
Date Format: MM slash DD slash YYYY
When did this condition begin?*
Date Format: MM slash DD slash YYYY
Did it begin gradually, suddenly or progress over time?*
- Gradual
- Sudden
- Progressive over time
What activities aggravate your symptoms?*
Is there anything, which has relieved your symptoms?*
- Yes
- No
Describe what has provided relief
Type of Pain*
- Select All
- Sharp
- Dull
- Ache
- Burn
- Throb
- Spasm
Does the Pain Radiate into your:*
- Arm
- Leg
- Does not radiate
Is this condition getting worse?*
- Yes
- No
How often do you experience these symptoms throughout the day?*
- 100%
- 75%
- 50%
- 25%
- 10%
- Only with activity
Does complaint(s) interfere with:*
- Work
- Sleep
- Hobbies
- Daily Routine
Have you been seen for this condition?*
- Yes
- No
How was it treated?
How did you respond to treatment?
SYMPTOMS QUESTIONNAIRE
Please select symptoms you're experiencing.*
This section is focused on misalignment of the neck region (cervical).
- Headaches
- Nervousness
- Insomnia
- Head Colds
- High Blood Pressure
- Migraine Headaches
- Nervous Breakdowns
- Amnesia
- Chronic Tiredness
- Dizziness
- Sinus Trouble
- Allergies
- Pain Around The Eyes
- Earache
- Fainting Spells
- Some Cases Of Blindness
- Crossed Eyes
- Deafness
- Neuralgia
- Neuritis
- Acne
- Eczema
- Hay Fever
- Runny Nose
- Hearing Loss
- Adenoids
- Laryngitis
- Hoarseness
- Throat Conditions (sore throat or quinsy)
- Stiff Neck
- Pain in Upper Arm
- Tonsillitis
- Chronic Cough
- Croup
- Bursitis
- Colds
- Thyroid Conditions
Please select symptoms you're experiencing.*
This section is focused on misalignment of the mid-back region (thoracic).
- Asthma
- Cough
- Difficulty Breathing or Shortness of Breath
- Pain in Lower Arms or Hands
- Functional Heart & Chest Conditions
- Bronchitis
- Pleurisy
- Pneumonia
- Congestion
- Influenza
- Gall Bladder Conditions
- Jaundice
- Shingles
- Liver Conditions
- Fevers
- Blood Pressure Problems
- Poor Circulation
- Arthritis
- Stomach Troubles or Nervous Stomach
- Indigestion
- Heartburn
- Dyspepsia
- Ulcers
- Gastritis
- Lowered Resistance
- Allergies
- Hives
- Kidney Troubles
- Hardening of the Arteries
- Chronic Tiredness
- Nephritis
- Pyelitis
- Skin Conditions (acne, pimples, eczema or boils)
- Rheumatism
- Gas Pains
- Certain Types of Sterility
Please select symptoms you're experiencing.*
This section is focused on misalignment of the low back region (lumbar).
- Constipation
- Colitis
- Dysentery
- Diarrhea
- Some Ruptures or Hernias
- Cramps
- Difficulty Breathing
- Minor Varicose Veins
- Bladder Troubles
- Menstural Troubles (painful or irregular periods)
- Miscarriages
- Bed Wetting
- Impotency
- Change of Life Symptoms
- Knee Pain
- Sciatica
- Lumbago
- Difficulty urinating (includes frequent or painful urination)
- Backaches
- Poor Circulation in the Legs
- Swollen or Weak Ankles & Arches
- Cold Feet
- Weakness in the Legs
- Leg Cramps
Please select symptoms you're experiencing.*
This section is focused on misalignment of the pelvis (sacrum).
- Sacro-iliac Conditions
- Spinal Curvatures
- Hemorroids
- Pruritis (Itching)
- Pain at the end of the spine while sitting
EXPERIENCE WITH CHIROPRACTIC CARE
Have you seen a chiropractor before?*
- Yes
- No
Who?
When did you last see them for care?
Date Format: MM slash DD slash YYYY
Reason(s) for previous chiropractic visits:
Did you know posture determines your health?*
- Yes
- No
Are you aware of any poor posture habits?*
- Yes
- No
Explain:
Are you aware of any poor posture habits in your spouse or children?*
- Yes
- No
- N/A
Explain:
HEALTH LIFESTYLE
Do you exercise*
- Yes
- No
How often?
- 1x per week
- 2x per week
- 3x per week
- 4x per week
- 5 or more times per week
Do you smoke?*
- Yes
- No
How much do you smoke?
Do you drink alcohol?*
- Yes
- No
How many drinks per week?
Do you drink coffee?*
- Yes
- No
How many cups per day?
Do you take any health supplements (vitamins, minerals, herbs, etc.)?*
- Yes
- No
What kind and how often?
Please list any health conditions not mentioned above:*
if none, simply enter "N/A"
Please list any medications you are currently taking and their purpose:*
if none, simply enter "N/A"
Please list all past surgeries:*
if none, simply enter "N/A"
Please list all previous accidents and falls:*
if none, simply enter "N/A"
HEALTH INSURANCE
Will you be using health insurance for your chiropractic care?*
- Yes
- No
Name of Primary Carrier
Insured Date of Birth
Date Format: MM slash DD slash YYYY
Address of Insured
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Insurance ID#
Group#
TERMS OF ACCEPTANCE & CONSENT TO CARE
TERMS OF ACCEPTANCE When a person seeks chiropractic health care and is accepted for such care, it is essential for both parties to be working towards the same objective. We have one main goal, to detect and correct/reduce the vertebral subluxation complex. It is important that each person understand both the objective and the method that will be used to attain this goal. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express it's maximum health potential. We do not offer to diagnose or treat a disease or condition other than vertebral subluxation. Regardless of what a disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our Only Practice Objective is to eliminate a major interference to the expression of the body's innate wisdom and ability to heal. Our only method is specific adjusting to correct vertebral subluxations. N01E: It is understood and agreed the amount paid to Revelation Chiropractic for x-ray, is for examination only and the x-rays will remain the property of this office, being on file where they may be seen at any time while a patient of this office.
CONSENT TO CARE I do hereby authorize the doctors of Revelation Chiropractic to administer such care that is necessary for my particular case. This care may include consultation, examination, spinal adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays or any other procedure that is advisable, and necessary for my health care. Furthermore, I authorize and agree to allow Revelation Chiropractic to work with my spine through the use of spinal adjustments and rehabilitative exercises for the sole purpose of postural and structural restoration to allow for normal biomechanical motion and neurological function. I have had an opportunity to discuss with the doctor of chiropractic and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures related to my health care. I understand that I am responsible for all fees incurred for the services provided, and agree to ensure full payment of all charges. I further understand that a fee for services rendered will be charged and that I am responsible for this fee whether results are obtained or not. I also clearly understand that if I do not follow the Doctors specific recommendations at this clinic that I will not receive the full benefit from the programs offered, and that if l terminate my care prematurely that all fees incurred will be due and payable at that time. I authorize the assignment of all insurance benefits be directed to the Doctor for all services rendered. I also understand any sum of money paid under assignment by any insurance company shall be credited to my account, and I shall be personally liable for any and all of the unpaid balance to the doctor.
TERMS OF ACCEPTANCE & CONSENT TO CARE*
I have read and agree to all terms of acceptance and consent to care.
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