PERSONAL INJURY QUESTIONAIRE
INFORMATION ABOUT YOU
Name _____________________Email________________ Phone __________________
Address _____________________ City _______________ State _____ Zip __________
Age______ Birthdate ________________ Sex ( )M ( )F S/S# ____________________
Employer’s Name______________________ Employer’s Address ______________________
Your Ins. Co. _________________________ Policy# _________ Agent’s Name __________
Name on Policy (if other than self) ___________________________ Policy # ______________
Responsible Party’s Name ________________________________________________________
Address ________________________ City _________________ State ___ Zip ________
Policy Holder’s Name ____________________________Policy # __________________ ___
INFORMATION ABOUT YOUR ATTORNEY
Name __________________________________ Phone ____________ Fax ____________
Address ________________________ City _______________ State ___ Zip __________
Were there any Witnesses? ( )Yes ( )No Names _______________________________
INFORMATION ABOUT YOUR ACCIDENT
1. Date of Accident ________________________ Time of Day _________________________
2. Were You: ( )Driver ( )Passenger ( )Front Seat ( )Back Seat
3. Number of people in your vehicle? ___________ Where you wearing seat belts? ( )Y ( )N
4. What direction were you headed? ( )North ( )East ( )South ( )West
5. What Direction was the other vehicle headed? ( )North ( )East ( )South ( )West
on (name of street) ___________________________________________________________
6. Were you struck from: ( )Behind ( )Front ( )Left Side ( )Right Side
7. Approximate speed of your car ________ MPH. Other car ________ MPH
8. Were you knocked unconscious? ( )Yes ( )No If yes, for how long? _______________
9. Were Police Notified? ( )Yes ( )No
10. In your own words, please describe the accident: ___________________________________
______________________________________________________________________________
______________________________________________________________________________
11. Did You have any physical complaints BEFORE THE ACCIDENT? ( )Yes ( )No
If yes, Describe: ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
12. Please Describe how you felt:
a. DURING the accident: ____________________________________________________
b. IMMEDIATELY AFTER the accident _________________________________________
c. LATER THAT DAY: ______________________________________________________
d. THE NEXT DAY: ________________________________________________________
13. What are your PRESENT complaints and symptoms?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
14. Do you have any congenital (from birth) factors which relate to this problem?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
15. Do you have any previous illness which relate to this case? ( )Yes ( )No
If yes, please Describe: ________________________________________________________
___________________________________________________________________________
16. Have you ever been involved in an accident before? ( )Yes ( )No
If yes, please describe, including date(s) and type(s) of accidents as well a injuries received:
___________________________________________________________________________
17. Where were you taken after the accident? _________________________________________
18. Have you been treated by another doctor since the accident? ( )Yes ( )No
If yes, names: _______________________________________________________________
19. Since this injury occurred, are symptoms ( )Improving ( )Getting Worse ( )Same
20. CHECK SYMPTOMS YOU HAVE NOTICED SINCE THE ACCIDENT:
( ) HEADACHE
( ) NECK PAIN
( ) NECK STIFF
( ) SLEEPING PROBLEMS
( ) BACK PAIN
( ) NERVOUSNESS
( ) TENSION
( ) IRRITABILITY
( ) CHEST PAIN
( ) DIZZINESS
( ) HEAD IS HEAVY
( ) PINS/NEEDLES ARMS
( ) PINS/NEEDLES LEGS
( ) NUMBNESS-FINGERS
( ) NUMBNESS-TOES
( ) SHORTNESS-BREATH
( ) FATIGUE
( ) DEPRESSION
( ) LIGHT SENSITIVE EYES
( ) LOSS OF MEMORY
( ) EARS RIGN
( ) FACE FLUSHED
( ) BUZZING IN EARS
( ) LOSS OF BALANCE
( ) FAINTING
( ) LOSS OF SMELL
( ) LOSS OF TASTE
( ) DIARRHEA
( ) FEET COLD
( ) HANDS COLD
( ) STOMACH UPSET
( ) CONSTIPATION
( ) COLD SWEATS
( ) FEVER
( ) ____________
21. Have you lost time from work as a result of this accident? ( )Yes ( )No
a. Last day worked: ___________________________________________________________
b. Type of employment: ________________________________________________________
c. Present Salary: ____________________________________________________________
d. Are you being compensated for time lost from work? ( )Yes ( )No
If yes, type of compensation you are receiving: ____________________________
22. Do you notice any activity restrictions as a result of this injury? ( )Yes ( )No
If yes, please describe: __________________________________________________________________________________________________________________________________
23. Other pertinent information: __________________________________________________________________________________________________________________________________________________________________________________________________________
PATIENT AUTHORIZATION REGARDING OUR OPEN DOOR ADJUSTING ENVIRONMENT, SIGN-IN, SHEETS, TRAVEL CARD USE AND PATIENT RECORD OF DISCLOSURES.
Our office uses sign in sheets, travel cards and provides care in an “open door” adjusting environment. Adjustments are done in an open adjusting area. As a result patients are in sight of each other and some ongoing routine details of care may be in earshot of other patients and staff. This environment is used for ongoing care and is not the environment for taking patient’s histories, performing examinations or presenting report of findings. These procedures are done in a private, confidential setting. If you choose not to be adjusted in an open-door adjusting environment, other arrangements will be made for you. Your signature below indicates your authorization for this activity. In addition your signature below authorizes us to contact you at all the phone numbers/address you list on this intake form. If you do not wish to be contacted at any listed numbers/address, please let us know.
TERMS OF ACCEPTANCE/ CHIROPRACTIC INFORMED CONSENT AGREEMENT
I hereby request and consent to the performance of chiropractic adjustments, other chiropractic procedures and, if necessary, diagnostic x-rays on me by Dr Jeff Gancas at Living Healthy Chiropractic and/or anyone authorized by the same doctor. I further understand and am informed that Living Healthy Chiropractic does not offer to diagnose or treat any disease or condition other then vertebral subluxation. However, if during the course of a chiropractic spinal examination, the doctor encounters non-chiropractic or unusual findings, he will inform me and offer a referral. Regardless of what the disease is called, the doctor will not offer to treat it, nor will he offer advice regarding treatment prescribed by others.
The main objective at Living Healthy Chiropractic is to eliminate interference to the expression of the body’s innate wisdom. As in all health care, there are some slight risks to treatment. I do not expect the doctor to be able to anticipate or explain all risks and combinations. I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, and is in my best interest.
The statements made on this form are accurate to the best of my recollection, and I agree to allow this office to examine me for further evaluation.
I have read this consent and intend this consent form to cover the entire course of my care for this condition and any care in the future.
PATIENTSIGNATURE:_________________________________PRINTNAME: _______________________________
LHCREPRESENTATIVE:____________________________________DATE:__________________________________
Worst pain Imaginable Feeling absolutely great
Level of discomfort right now
Best it has felt in the past week (or since the last form)
Worst it has felt in the past week (or since the last form)