AUTOMOBILE ACCIDENT HISTORY FORM

(1)

AUTOMOBILE ACCIDENT HISTORY FORM

Your Name

Date Of Accident Time Of Accident am/pm City Of Accident Street Of Accident

Road Conditions At The Time Of Accident: Wet Dry Ice Other:

Did the police come to the accident scene? Yes No Was there a report? Yes No Did you go to the hospital? Yes No

If yes, what is the name of the hospital? How did you get to the hospital?

What parts of your body were x-rayed at the hospital? What did the hospital do for your injuries?

How long did you stay at the hospital?

What bleeding cuts did you sustain during this accident? What bruises did you sustain during this accident? Where were you seated in the vehicle?

Were you aware of the approaching collision prior to impact? Yes No

Did you lose consciousness (black out) upon impact? Yes No How long? Did you experience a flash of light or explosion in your head? Yes No

Did you experience any of these due to the accident? (Please circle) Confused; Disoriented; Light Headed;

Dizzy; Nauseated; Blurred Vision; Ring/Buzz in Ears

Are you currently suffering from any of the following (please circle)? Restlessness; Irritable; Difficult

Concentrating; Difficult with Memory; Sleeplessness; Forgetfulness; Reduced Tolerance to Heat; Reduced Tolerance to Alcohol

How far is the top of the headrest or seatback from the top of your head (approximately)? Inches above/below

Please describe, to the best of your knowledge, what happened during the accident: Are you currently working? Yes No Off work on:

Returned to work on:

File#: Today’s Date

(2)

Patient Vehicle:

List the year, make and model of the vehicle you were in:

Year Make Model

Was the car stopped at the time of impact? If yes, was the driver’s foot also on the brake?

If no, then estimate the speed of the vehicle you were in: mph If your vehicle was moving at the time of impact, was it:

Slowing down? Gaining speed?

Traveling at a steady speed? Yes No

On what part of the automobile did your following body parts hit?

Head hit Chest hit

Rt/Lt Shoulder hit Rt/Lt arm hit

Rt/Lt Hip hit Rt/Lt Leg hit

Rt/Lt Knee hit Other:

Which of the following vehicle parts broke during the accident? (please circle)

Windshield Front Seat Back Right/Left Side Window

Steering Wheel Other:

Was the trunk of your body pointed straight forward at the time of the collision? Yes No If no, how was it turned?

Was your head pointed straightforward? Yes No If no, what direction was it turned and by how much? Were you wearing a seatbelt? Yes No

If yes, was it a lap seatbelt or shoulder-lap seatbelt? (circle one) Did you receive any injury or bruise from the seatbelt? Yes No If yes, then describe:

What is the estimated cost of damage to the vehicle you were in? $ Insurance Company:

Policy: Claim#:

Conact person: Phone#:

Other vehicle

List the year, make and model of the other vehicle:

Year Make Model

Was the other vehicle moving at the time of the collision? Yes No If yes, what was its approximate speed? mph

If the other vehicle was moving at the time of collision, was it (please circle):

Slowing Down Gaining Speed Traveling at a Steady Speed

Insurance Company:

Policy: Claim#:

Conact person: Phone#:

Signature: Date:

(3)

SHEPPARD CHIROPRACTIC

Dr. Joseph A. Sheppard

3878 McMann Rd., Cincinnati, OH 45245 (513) 753-7246 (p) ~ (513) 753-7517 (f)

CASE HISTORY

Name: _________________________________ File#: ______________ Circle the severity (0 = No Pain to 10 = Very Severe Pain) and Frequency of pain (% of the Day you experience the pain).

Condition / Problem Severity Frequency (% of Day)

Occasional Constant

1.

Minimal Severe

0 1 2 3 4 5 6 7 8 9 10 0 10 20 30 40 50 60 70 80 90 100 Symptom is: Aching / Burning / Dull / Sharp / Stiff / Throbbing / Stabbing / Numbness / Tingling / Pins & Needles 2. 0 1 2 3 4 5 6 7 8 9 10 0 10 20 30 40 50 60 70 80 90 100 3. 0 1 2 3 4 5 6 7 8 9 10 0 10 20 30 40 50 60 70 80 90 100 4. 0 1 2 3 4 5 6 7 8 9 10 0 10 20 30 40 50 60 70 80 90 100 5. 0 1 2 3 4 5 6 7 8 9 10 0 10 20 30 40 50 60 70 80 90 100 6. 0 1 2 3 4 5 6 7 8 9 10 0 10 20 30 40 50 60 70 80 90 100 7. 0 1 2 3 4 5 6 7 8 9 10 0 10 20 30 40 50 60 70 80 90 100

(Please mark the figures where you experience pain.) 8. Symptoms are worse in the (circle what applies)

-Increase during the day

-morning -afternoon -night

-same all day

9. When did your symptoms begin (onset date)? __________________________________________________________ 10. How did your symptoms begin? _____________________________________________________________________ 11. Have you experienced these before? _________________________________________________________________ 12. Do your symptoms travel down your Legs / Arms? ____________________________________________________ 13. Has your condition? ____ Improved ____ Gotten Worse ____ Stayed the same since it began

14. Circle the things that make your problems worse:

Bending - Lying - Walking - Standing - Sitting - Movement - Twisting - Lifting - Sleeping - Turning - _____ Limited to ____________________________________________________________________________________

-decrease during the day

Symptom is: Aching / Burning / Dull / Sharp / Stiff / Throbbing / Stabbing / Numbness / Tingling / Pins & Needles

(4)

Name: _________________________________ File#: ______________

15. Is there anything you can do to relieve the problems? ____No ____Yes Describe: __________________________ If No, what have you tried that has not helped? _______________________________________________________ 16. Have you been treated for this before? ____No ____Yes How long ago? ___________________________________ 17. What treatment did you receive? ____________________________________________________________________ 18. Results of previous treatment? ____Good ____Poor Comments _________________________________________ 19. Were you referred to our office by anyone? ____________________________________________________________ 20. Is this condition interfering with ____ Work ____Sleep ____Daily Routine ____Recreation None

21. List any other major injuries or traumas you have had, other than those mentioned above: None

___________________________________________________________________________________________________ 22. Any other Musculoskeletal problems? ____No ____Yes Neurological problems? ____No ____ Yes

23. Review of Systems: Neg ______________________________ 24. Medications: None / See Attached List

1. ___________________ 2. ___________________ 3. ___________________ 4. ___________________ 5. _____________________ 6. ___________________ 25. Allergies: None

1. ____________________ 2. ___________________3. ___________________ 4. ____________________ 26. Vitals:

L / R Sitting Blood Pressure ______ Pulse ________ BPM Respiration_______ RPM Height ___ ft ____ in Weight _______ Lbs.

27. Surgeries: None

1. ____________________2. ____________________3. ____________________4. ____________________ 28. Current and Past Health Conditions: None

1. ______________________ 2. _________________ 3. ___________________ 4. ______________________ 5. _________________ 6. ___________________

29. Family History: None Cancer Diabetes HBP Heart Attack/Disease Cholesterol Stroke Arthritis _________ 30. Exercise/Diet

Do you exercise? _____ per week No Eat Healthy Y / N Take Vitamins Y / N 31. Tobacco/Alcohol Use:

Smoking Yes / No Tobacco Yes / No Drink Alcohol Yes / No Socially

I certify that the above information is accurate to the best of my knowledge.

Patient/Guardian Signature ___________________________________________ Date: ______________

(5)

Work Ph Best time to call: am/pm

Zip

Married Widowed Separated Divorced Number of Children

Home Ph Cell Ph

Name

Street Address

City State

Social Security Number

Sex M F Age Birth date Single Email Address

How and where did you learn about this clinic?

Condition / Illness Related To: Illness Employment Automobile Other

By subscribing my name and signature below, I acknowledge that I have received a copy of the HIPAA guidelines and am in agreement to, and understanding with, its terms and conditions.

Signature: _____________________________________ Date: ____________

I hereby authorize Sheppard Chiropractic, Inc. and whomever they may designate as their clinicians to administer care as they so deem necessary to my son/ daughter / ward.

Signaure of Parent or Guardian: Date:

Company Name Occupation

Address Phone Full-time Part-time

City State Zip

Name

Birthdate Social Security Number

Employer Name Occupation

Address Phone

City State Zip

SPOUSE (PARENT)

A MINOR

Sheppard Chiropractic, Inc.

REGISTRATION

EMPLOYER

3878 McMann Rd. Cincinnati, Ohio 45245 (513) 753-5437

HIPAA PRIVACY STATEMENT

AUTHORIZATION FOR CARE OF

City State Zip

Are your present symptoms or conditions related to or the result of an auto accident, work-related injury or personal injury someone else might be legally responsible for? Yes No Your Initials

Insurance Company: Policy ID #:

Subscriber: Subscriber Date of Birth: Subscriber SSN:

Signature of Insured / Guardian Date

AGREEMENT PATIENT INSURANCE INFORMATION

LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS

In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to Sheppard Chiropractic all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions.

I hereby convey to the above named doctor and clinic to the full extent permissable under the law and under any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissable under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation , I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic's expenses.

Should this assignment be prohibited in part or in whole under any anti-assignment provision of my policy/plan, please advise and disclose to my provider in writing such anti-assignment provision within 30 days upon receipt of my assignment, otherwise this assignment should be reasonably expected to be effective and such anti-assignment is waived. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement.

(6)

SHEPPARD CHIROPRACTIC

This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that an x-ray can be hazardous to an unborn child. Date of last menstrual period:

Signature Date

TERMS OF ACCEPTANCE

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective.

Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. 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 of correction is by specific adjustments of the spine.

Health: A state of optimal physical, mental and social well-being, not merely the absence of 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 of the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specialized in that area.

Regardless of what the 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. Our only method is specific adjusting to correct vertebral subluxations.

I, , have read and fully understand the above statements.

Print Name

All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis.

Signature Date

Consent to evaluate and adjust a minor child.

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.

(7)

DATE: / /

PATIENT: ACCT#:_________________

DATE OF BIRTH: / / SSN: -

-DATE OF RECORDS:

These records are needed immediately in order to properly process this patient.

Radiology Reports (X-rays, MRI, CT) Films in question:

Actual film copies of X-rays / MRI's / CT's (by mail).

Office Notes and Dictations

Emergency Room Records / Lab Reports / Diagnostic Studies

PATIENT REQUEST FOR RECORDS

Emergency Room Records / Lab Reports / Diagnostic Studies

Ambulance Transporter's Report

Special Studies (i.e. NCV, EMG, etc.)

Surgical / Post-Surgical Reports

Other:_________________________________________________________

I HEREBY AUTHORIZE THE RELEASE OF MY X-RAYS / RECORDS AND REQUEST THAT THEY BE TRANSFERRED TO:

PATIENT SIGNATURE: DATE: / / Phone: 513-753-5437 Fax: 513-753-7517 Sheppard Chiropractic 3878 McMann Rd. Cincinnati, OH 45245

Note of Confidentiality: This is intended for use only by the individual or entity to which it is addressed and may contain information that is

privileged, confidential, and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone, so that all transmitted materials received may be dealt with appropriately. Thank you.

(8)

DIAGNOSTIC IMAGING CONSULTANTS, INC.

3296 W. St Route 22-3

Loveland, OHIO 45140

(513) 489-0055

FAX: (513) 489-4587

ASSIGNMENT OF BENEFITS

FOR RADIOGRAPHIC INTERPRETATION

I understand that to insure the highest quality of interpretation of my x-rays, the services of a certified chiropractic radiologist are being utilized. This fee is separate from that of the chiropractic clinic. I also understand that the fees for this service will be submitted to my insurance carrier, Worker’s Compensation, or attorney in the case of personal injury.

I understand I may receive a billing statement for: insurance denial, professional fees that have been applied to my deductible, or the balance due stated by my insurance company as my responsibility.

In the event that I receive payment for the services I agree to promptly remit payment to Diagnostic Imaging Consultants.

I acknowledge and give my consent to have my x-rays interpreted by Dr. Bryan Hosler, DACBR . I understand that any balance due is my responsibility.

SIGNATURE:_______________________ DATE:______________________

Healthcare information is sensitive information. It is being sent to us after the appropriate authorization of the patient. We the recipient are obligated to maintain it in a safe, secure, and confidential manner. Re-disclosure without additional patient consent or as permitted by law is prohibited. Unauthorized Re-disclosure could subject penalties described in federal law.

The following signature authorizes the release of medical information and also authorizes the assignment of benefits to:

DIAGNOSTIC IMAGING CONSULTANTS, INC. 3296 West State Route 22-3

Loveland, Ohio 45140

SIGNATURE: ___________________ DATE: _______________________ WITNESS: _________________________________

(9)

SHEPPARD CHIROPRACTIC

February 1, 2014

A General Announcement to All Our Patients

As a "Courtesy" Sheppard Chiropractic will verify chiropractic benefits on your

insurance policy. We do our best to get accurate information, however, you are ultimately responsible for any balance your insurance does not pay. It is your responsibility to

know if you have Chiropractic Benefits. Insurance Claims Policy Change

As usual, we will continue to file the initial claim for you or your child's chiropractic treatment. Most insurance companies automatically generate continuation of fee payments until the maximum is reached.

However, it is increasingly becoming more difficult to get insurance companies to pay. As a result, our insurance department is spending hours and hours trying to get some insurance companies to pay. In some cases, we have been trying for over a year to get a claim paid.

Due to this, we will now attempt to get your claim paid for three months. In the fourth month, if your claim has not been paid, you will be responsible to contact your

insurance company and have them pay your benefits to us. If you choose not to do

this, we will add the amount of uncollected benefit to your portion of the financial contract, and you will be responsible to pay it.

If you have any questions feel free to call Maureen or Kristina in the insurance department at

(513)-753-7246.

Thank you for your cooperation in this matter.

X

Date:_____

/

_____

/

_________

3878 McMann Rd.

•