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)