PATIENT INJURY/MEDICAL HISTORY FORM

Personal Injury / Accident
Medical History Intake Form
Release Chiropractic and Wellness Center
Please provide your Driver’s License to our staff for your file.
ABOUT YOU
Full Name: __________________________________________ Gender
M
F Age:_______ Birth Date: _____/_____/_____
Address: ___________________________________________ City: ____________________
State: ______ Zip: ___________
Social Security#: ______-_____-______ Driver’s License #: _________________________ Home Phone: (____) ______________
Spouse’s Name: ______________________
Referred by: ____________________________ Cell Phone: (____) ______________
Employer: _______________________ Occupation: ________________________________ Work Phone: (____) ______________
Employer Address: ____________________________________ City: ______________________ State:______ Zip: ____________
INSURANCE/ATTORNEY INFORMATION
Insurance Company of the Person at Fault: _____________________________________ Name of Agent: ______________________
Insurance Company Address: ______________________________ City: __________________
State: ______ Zip: ___________
Insurance Company Phone #: _________________________________ Agent’s Phone #: ___________________________________
Claim Number: _______________________________________________________
Your Attorney’s Name:__________________________________
Have you retained an attorney?
Yes
No
Your Attorney’s Phone: _________________________________
Your Attorney’s Address: _________________________________ City: ___________________
State: ______ Zip: __________
ACCIDENT INFORMATION
Date of Accident: ______/______/______
Time of Accident: ____________
a.m.
p.m.
Your Vehicle: Year ____________ Make _______________ Model ________________________ Your Speed ___________________
Other Vehicle: Year ___________ Make _______________ Model ________________________ Other Vehicle Speed ____________
Accident Type:
Rear ended
Head-on
Broad-sided
Damage to Your Vehicle: $_______ Other Vehicle Damage: $ ______
Describe the Accident:
___________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537
ACCIDENT SPECIFICS (Mark each that applies to the accident):
Job or work related injury
Were you the
If the passenger, were you
Were you wearing your seatbelt?
Impending collision, were you
 Yes
 Driver
 Front seat
 Yes
 Aware
 Braced
 Strike object
 Break glass
 Shock
 Flash of light seen upon impact
 Yes
Did your head…
Did you experience…
Did the airbag deploy?
IMMEDIATELY FOLLOWING THE ACCIDENT:
 No
 Passenger
 Back seat
 No
 Unaware
 Not braced
 Not strike object
 Loss of consciousness
 No
OTHER DOCTORS SEEN:
Ambulance / Paramedics were called
Orthopedist
I was treated at scene
Psychiatrist
Transported to hospital by ambulance
Massage Therapist
I went to Hospital on my own
Neurologist
I was diagnosed at the Hospital
Physical Therapist
I was treated at the Hospital
Chiropractor
Medication was prescribed
Other
Follow-up was recommended
THE WEATHER WAS:
THE ROAD WAS:
TIME OF DAY:
Dry
Dry
Dawn
Sunny
Wet
Day
Rainy
Icy
Dusk
Snowy
Snowy
Night
Cloudy
Foggy
State your Emotions and Physical State immediately following the accident: _______________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
State your Emotions & Physical State after the first few days: __________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537
SYMPTOMATOLOGY (Pain Characteristics for Major Area of Complaint):
The pain started _____________________________________________________________________________________________
The pain is made better by ____________________________________________________________________________________
and worse by ________________________________________________________________________________________________
The pain has the following qualities: ____________________________________________________________________________
There is
There is not
radiation into
____________________________________________________________________
There is
There is not
referred pain into
_________________________________________________________________
There is
There is not
parasthesia (tingling/numbness) into:______________________________________________ _____
The pain is located ___________________________________________________________________________________________
The pain is (as far as timing is concerned: i.e. comes & goes, constant, etc.)______________________ ____________________ ___
DAILY ACTIVITIES
PAIN RATING
How many days out of an average week do you have pain? __________
On a scale of 1- 10, rate your pain
How much time out of an average day are you in pain? _____________
What are the worst times of day for the pain? _____________________
What are the best times of day for the pain? _______________________
How do the following activities affect your pain?
No Change
Relieves Increased
Sitting
Walking
Standing
Lying Down
Looking up
Looking Down
Lifting
Duration
________
________
________
________
________
________
________
None
0 1 2 3 4 5 6 7 8 9 10
Severe
Describe the overall severity of the pain
Mild Nuisance
Mild to moderate but can live with it
Moderate, having trouble coping with it
Severe, it is ruining my quality of life
Progression
How is your pain compared to when it first
appeared?
Much improved
Somewhat improved
No change
Somewhat worse
Much worse
What do you do to relieve the pain? _____________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What are some recreational activities that you participated in before this current problem and which ones cannot be
performed now to the same extent as before? _____________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
List your hobbies and exercise activities: ________________________________________________________________________
____________________________________________________________________________________________________________
Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537
Please mark each that applies to your Daily Activities:
Has difficulty climbing stairs.
Stays at home most of the time due to the problem.
Changes position frequently to try and get comfortable.
Walks more slowly than usual because of the problem.
Does not do jobs around the house because of the problem.
Has to use handrails to get up stairs, etc.
Has to lie down and rest frequently due to the problem.
Has to hold onto something to sit or stand from a chair.
Has to get other people to do things for you.
Has difficulty getting dressed due to the problem.
Can only stand for short periods due to the problem.
Has difficulty bending or kneeling due to the problem.
Has difficulty turning over in bed due to the problem.
Has a loss of appetite due to the problem.
Can only walk short distances because of the problem.
Has difficulty sleeping because of the problem.
Has to get dressed with someone’s help.
Has to sit most of the day because of the problem.
Is more irritable because of the problem.
Stays in bed most of the day because of the problem.
How often do you have to stop activities
and sit or lie down to control your
symptoms?
Several times a day
Occasionally
Approximately once per day
Never
All day
SOCIAL HISTORY
Single
Married
Divorced
Children
How many? _________
Smoker
Non-smoker
Drinks alcohol
Do not drink alcohol
Take recreational drugs
Do not take recreational drugs
OCCUPATIONAL HISTORY
Your Employer ___________________________________________
Job Title ________________________________________________
Are your Job Duties physically demanding for you?
Have you had any disability time?
Yes
Yes
No
What is your current job satisfaction:
Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
No
If you are currently working, which are you performing?
Regular Duties
Limited – Light Duties
Your highest level of education attained?
___________________________________
MEDICAL HISTORY
List the Physicians and other practitioners your have seen for this problem: List the Medications you are currently taking:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
List the treatments you have had for your problem
Hot packs / Ultrasound
Chiropractic
Massage
Osteopathy
Electrical Stimulation
Biofeedback
TENS Unit
Trigger Point Injections
Body Mechanics Training
Epidural Injections
Strengthening Exercises
Back Brace
Aerobics
Acupuncture
Gravity Inversion – Traction
Naturopathy
List the types of Diagnostic Testing that has been
performed for this problem
X-rays
CT Scan
Myelogram
MRI Scan
Discogram
Bone Scan
EMG
Bed Rest
Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537
List Past Surgeries
None
___________________________________________________
List Past Hospitalizations
None
__________________________________________________
___________________________________________________
__________________________________________________
___________________________________________________
__________________________________________________
___________________________________________________
__________________________________________________
List previous back, neck and musculoskeletal problems
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Mark if you have had any of the following symptoms in the past 5 years.
Females – Mark if have the following:
Unexplained fevers
Swollen ankles
Vaginal bleeding other than period
Night sweats
Stomach pain
Pap smear within last two years
Weight loss of 10 lbs or more
Change in bowel habits
Painful menstrual periods
Loss of appetite
Persistent diarrhea
Back pain with menstrual periods
Excessive fatigue
Excessive constipation
Other menstrual problems
Problems with depression
Dark black stools
Difficulty sleeping
Blood in stools
Unusual stress at work
Pain-burning when urinating
anxiety
Unusual stress at home
Difficulty urinating – start / stop
depression
Easy bruising
Blood in urine
irritability
Excessive bleeding
Need to urinate more at night
Lumps in neck, armpit or groin
Morning stiffness
Chest pain or tightness
Persistent eye redness
Persistent or unusual cough
Muscle tenderness
Trouble breathing with exercise
Dry eyes or mouth
Trouble breathing lying flat
Skin rashes
Coughing up blood
Joint pain or swelling
Do you have any current problem with:
Do you have a home exercise program that you follow on a regular basis?
Yes
No
Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537
Assignment of Benefits In Personal Injury Cases
I authorize Release Chiropractic and Wellness Center to receive lien payment from all liable insurance
companies, attorneys, or myself for all monies due on my account. I understand that all coverage in effect at the time of
my injury will be billed. Any overpayments will be promptly returned to me. In the event that there is no valid coverage
or that I have exceeded my insurance limit, I will remain responsible for charges incurred.
Further, I hereby authorize Release Chiropractic and Wellness Center or any of their employees to sign my
name on the back of any draft or check which they receive from my insurance company for services rendered, whether
pursuant to medical payments coverage or health insurance coverage, as long as I have an outstanding balance with them.
Said amount shall be credited against my account and shall reduce my outstanding balance accordingly.
All fees are based upon individual services rendered, and may vary from visit to visit depending upon the doctors
specific recommendations. A complete list is available at the front desk.
Initial Consultation: This is an opportunity to discuss with the doctor your concerns and their suggestions.
There is no charge for this consultation. (The initial consultation does not include any exams, therapy or X-rays).
Note: Unless all proper claim and insurance information is provided, the patient will be responsible for payment
of care received after the first visit until the necessary information can be validated.
A charge of $25.00 will be assessed for a missed appointment. This fee will require payment at the next visit. We
require a 24-hour notice for cancellations.
If the case is not settled within 120 days of being released from active care, the patient will be
responsible to begin making monthly payments until the balance is paid by the insurance company.
I agree to the terms above, and acknowledge that in the event that there is an outstanding balance, which fails to
be cured within sixty (60) days, my account with Release Chiropractic and Wellness Center will be turned over to
collection. I understand that should this happen, I will remain responsible for any and all additional collection fees and/or
attorney and court costs.
(Please initial to show your agreement.)
______________________________________________
Name
______________________________________________
Signature
__________________________
Date
Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537
Notice of Doctor’s Lien
Patient’s Name: ________________________________________________________
Healthcare Provider:
Release Chiropractic and Wellness Center
640 East Eisenhower Blvd. Suite 100
Loveland, CO 80537
Phone: 970-667-3393 Fax: 970-203-9690
I hereby authorize the above-mentioned healthcare provider to furnish the below-mentioned attorney with a full report of
his/her examination, diagnosis, treatments records, etc., of myself in regard to the accident in which I was involved.
I hereby further authorize and direct you, my attorney to pay directly to said healthcare provider such sums as may be due
and owing the office for professional services rendered me both by reason of this accident and by reason of any other bills
that are due to the office and to withhold such sums from any settlement, judgment or verdict as may be necessary to
adequately protect said healthcare provider. I hereby further give a lien on my case to said healthcare provider against any
and all 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 fully understand that I am directly and fully responsible to said healthcare provider for all professional bills submitted by
him/her for services rendered me and that this agreement is solely for said healthcare provider’s additional protection and
in consideration of his/her awaiting payment. Further, I understand that such payment is not contingent on any settlement,
judgment or verdict by which I may eventually recover said fee.
________________________________________
Name
________________________________________
Signature
____________________________
Date
(Patient, please do not write below this line.)
**************************************************************************************************
The undersigned being attorney of record for the above patient does hereby agree to observe all the terms of the above and
agrees to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately protect the said
healthcare provider named above.
Attorney Name: ________________________________________________________________________
Attorney Address: _______________________________________________________________________
_______________________________________________________________________
Date: _______________________ Attorney’s Signature: _________________________________________
Please return to:
Release Chiropractic and Wellness Center
640 East Eisenhower Blvd. Suite 100
Loveland, CO 80537
Phone: 970-667-3393 Fax: 970-203-9690
Please maintain a copy for your records.
Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537
Release Chiropractic HIPAA Acknowledgement
Patient Acknowledgment and Receipt of Notice of Privacy Practices Pursuant
to HIPAA and Consent for Use of Health Information
Patient Name: ___________________________________________
Date of Birth: ___________________________________________
The undersigned does hereby acknowledge that he or she has received a copy of this office’s Notice of Privacy
Practices Pursuant to HIPAA and has been advised that a full copy of this office’s HIPAA Compliance Manual
is available upon request.
The undersign does hereby consent to the use of his or her health information in a manner consistent with the
Notice of Privacy Practices Pursuant to HIPAA, the HIPAA Compliance Manual, State Law, and Federal Law.
Date: _____________________________________________
By: ______________________________________________
Patient’s Signature
If patient is a minor or under a guardianship order as defined by State law:
By: ______________________________________________
Signature of Parent/Guardian (circle one)
Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537