Patient Questionnaire – Auto-Collision
Patient Name: (First)__________________________(Middle)_____________________(Last)_________________________(Suffix)______ Today's Date: _____/_____/_____ Birth Date: ____/____/____ Age: ______ SSN: ____________________________ Gender: (circle) F M Height: _____ft_____in Weight: ______lbs (circle one) Right handed Left handed
If you are under 18 years of age, who are your legal parents or guardians?
Father: __________________________________ Date of birth: ____/____/____ Phone: (____) ______________________ Mother: __________________________________ Date of birth: ____/____/____ Phone: (____) ______________________ Guardian: _________________________________ Date of birth: ____/____/____ Phone: (____) _____________________ Who do you normally live with?
□
Mother and Father□
Father□
Mother□
Legal Guardian□
OtherCurrent Address and Information
Street: ___________________________________________________________________________________________________ City: _________________________________________ State: __________________________ Zip: ________________________ Phone: (______) ___________________________ Cell: (______) _____________________________
EMAIL: ____________________________________________________________________________
How did you hear about us? ________________________________________________________________________________________ Your occupation: __________________________________________ Employer: _______________________________________________ Work Address: __________________________________________________ Work Phone: (______) ______________________________ Student at: _____________________________________________________
□
Full-Time□
Part-TimeMarital Status:
□
Married□
Separated□
Divorced□
Widowed□
Single How many children? ________________ Name of Spouse: ______________________________________________ Spouse’s Date of Birth: ____/____/____Spouse’s SSN: ________________________________________________
Spouse’s Occupation: _________________________________________ Spouse’s Employer: ____________________________________ Spouse’s Work Address: ___________________________________________ Spouse’s Work Phone: (______) ______________________ Spouse is a student at: __________________________________________________
□
Full-Time□
Part-TimeCollision- (Basic Information)
Date Collision Occurred: _____/_____/_____ Time of Day when Collision Occurred: _____:_____ AM / PM
Describe how the Collision took place: ______________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ Describe the condition or symptoms caused by the Collision: _____________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________
Collision- (Specific Information)
Were you the:
□
Driver□
Passenger□
PedestrianAutomobile you were in: Year _________ Make ________________ Model _______________
Damage to your car:
□
Front□
Rear□
Pedestrian□
Driver Side□
Passenger Side□
Bumper□
Fender Damage amount to your car:□
Minor□
Major□
TotaledOther Automobile Involved: Year _________ Make ________________ Model _______________
Damage to other car:
□
Front□
Rear□
Pedestrian□
Driver Side□
Passenger Side□
Bumper□
Fender Damage Amount to other car:□
Minor□
Major□
TotaledWhere did the accident happen? Street Names: __________________________________ City/State _____________________________ Was it?
□
Controlled Intersection□
Uncontrolled□
Not IntersectionWas there a traffic light?
□
None□
Green□
Red□
Turn Arrow□
Stop Sign Were you:□
Slowly Moving□
Moving□
StoppedWeather Conditions:
□
Sunny□
Rainy□
CloudyStreet Surface:
□
Dry□
Wet□
Slick□
Icy□
Pavement□
Other ______________________ Type of Impact:□
Rear end□
Front□
Side Impact□
Roll OverBrakes on Impact:
□
Locked Tight□
Loosely Applied□
Foot not on brakeHow far did your car move upon impact?
□
Did not move□
Moved 1-10 ft□
Moved 10-20 ft□
Moved over 20-30 ft Where were you seated in the vehicle: __________________________________ Wearing Seat belt?□
Yes□
No Shoulder harness:□
Yes□
No Headrest:□
Yes□
No Headrest Position:□
Up□
DownIs the car equipped with airbags?
□
Yes□
No Did they deploy?□
Yes□
NoDid you see the impact coming?
□
Yes□
No Did you brace yourself for impact?□
Yes□
NoOn impact, your head was looking:
□
Ahead□
Behind□
Up□
Down□
To the Right□
To the LeftOn impact were you:
□
Thrown forward□
Thrown backwards□
Thrown sideways□
Other ______________________Did your body hit anything inside the car?
□
Yes□
No Body Part: ______________________ What did it hit? ____________________ Head trauma?□
Yes□
No Loss of Consciousness?□
Yes□
No For how long? _________________________Do you remember the accident happening?
□
Yes□
NoHospital?
□
Yes□
No Hospital name: _______________________________ How long were you there? _________________________ Taken by ambulance?□
Yes□
NoAdditional Information Related to the Condition:
Circle areas of pain on diagram below
Describe your pain:
□
Sharp□
Dull□
Stabbing□
Aching□
Radiating□
Burning□
Throbbing Describe the intensity of pain:□
Minimal□
Mild□
Moderate□
SevereHow often do you experience the pain?
□
Infrequent□
Occasional□
Intermittent□
Frequent□
ConstantWhat caused the pain? ____________________________________________________________________________________ What increases the pain?
□
Sitting□
Standing□
Walking□
Running□
Lifting□
Time on computer□
Time on phone□
Working overhead□
SleepingWhat decreases the pain?
□
Rest□
Ice□
Heat□
Sleeping□
Sitting□
Standing□
Walking□
Stretching How long has the pain been occurring?□
Hours□
Days□
Weeks□
YearsHas the Patient ever had the same or similar condition or symptoms previous to this most recent occurrence?
□
Yes□
No When? _____/_____/_____Describe: ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ Please indicate any other healthcare providers that have been seen for the condition or symptoms:
Name Type of Licensure Date of Last Visit
____________________ ____________________________ ______/______/______
Please check any of the following symptoms you are now experiencing:
□
Headache□
Dizziness□
Light Bothers Eyes□
Diarrhea□
Head seems too heavy□
Neck Pain□
Loss of Memory□
Lightheaded□
Feet Cold□
Neck Stiff□
Tingling in arms/hands□
Ears Ring□
Hands Cold□
Sleeping Problems□
Tingling in legs/feet□
Face Flushed□
Nausea□
Back Pain□
Numbness in arms/hands□
Clumsiness□
Constipation□
Nervousness□
Numbness in legs/feet□
Loss of Balance□
Cold Sweats□
Tension□
Shortness of Breath□
Fainting□
Fever□
Fatigue□
Irritability□
Loss of Smell□
Chest pain/rib pain□
Pain in arms/hands□
Pain in legs/feet□
Jaw pain□
Loss of strength - arms□
Burning muscle pain□
Loss of strength - legs□
Difficulty swallowing□
Sharp/shooting pain□
Other ___________________________________Have you experienced changes to:
□
Eyes (sight)□
Ears (hearing)□
Nose (smell)□
Mouth (taste)□
Bladder□
Bowels□
Sleep□
Emotion□
AppetitePlease Explain: ________________________________________________________________________________________________________ Have you missed work or school due to your injuries?
□
Yes□
No How much time? ______________________________________________ Any limitations to your normal daily activity?□
Yes□
No Please Explain: _______________________________________________________ _____________________________________________________________________________________________________________________Medical History:
Do you currently smoke?
□
Yes□
No Number of packs weekly: __________Have you ever smoked?
□
Yes□
No Number of packs weekly: __________ When did you quit? ____/____/____ Do you drink alcohol?□
Yes□
No Number of drinks weekly: __________List any previous accidents (automobile, on the job injuries, slips, falls, sports, etc.) and provide the accident date:
1) ________________________________________________________________________________ _____/_____/_____
2) ________________________________________________________________________________ _____/_____/_____
3) ________________________________________________________________________________ _____/_____/_____
Surgeries/Hospitalizations: ______________________________________________________________________________________________ Allergies (please list all): ________________________________________________________________________________________________ Do you now or have you ever had:
□
Heart Disease□
Diabetes□
Cancer□
Stroke□
High Blood Pressure□
Thyroid Problems□
Tuberculosis□
Prostate Disorder□
Kidney Problems□
Asthma□
Ulcer□
Seizure DisorderOther: _____________________________________________________
Personal Injury or Claim Information:
Did police arrive on scene of collision?
□
Yes□
No Citation Issued?□
Yes□
No To whom? ______________________________ My Auto Insurance Company: ___________________________________ Address: _______________________________________________ Phone: (_____) ___________________ Claim #: ______________________________ Policy #: ________________________________ Is MedPay on this policy?□
Yes□
No
My Group/Individual Insurance Company: ____________________________________ Address: _____________________________________ Phone: (_____) ___________________ Claim #: ______________________________ Policy #: ________________________________ Insurance Company of Person Responsible For Injury: _______________________________________________________________________ Address: ______________________________________________________________________________________________________ Phone: (_____) ___________________ Claim #: ______________________________ Policy #: ________________________________ Have you been contacted by an insurance adjuster or representative on this claim?
□
Yes□
No Claim #: __________________________ Adjuster’s Name: _______________________________ Adjuster’s Phone: (_____) __________________________________________ Adjuster’s Fax: (_____) __________________________Attorney Name: ______________________________________ Address: ________________________________________________________ Phone: (_____) ________________________________ Fax: (_____) __________________________
How will account be paid:
□
Self pay□
Auto Insurance□
Other: ____________________________________________I hereby authorize LeRay Chiropractic, PLLC to release medical information if necessary to process this claim. Patient Signature: ___________________________________________
Date: _________________________________
***************************************************************************************************************************** ************************************** Payment Expected At Time Of Visit Unless Other Arrangements Have Been Specified
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself.
Furthermore, I understand LeRay Chiropractic, PLLC will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to LeRay Chiropractic, PLLC will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. Any accounts that are referred for collection will have a service fee charged at the time of referral to cover additional handling costs. Should legal action be necessary for the recovery of any monies due under this agreement, the prevailing party shall be entitled to recover attorney fees and court costs from the other party. Any disputes between parties shall be resolved by binding arbitration. It is not our intention to cause you undue hardship, however we must collect our receivables as efficiently as possible in order to continue our service to the community. Interest of 1.5% per month will be charged on delinquent accounts. If you discontinue care, all charges are due and payable immediately.
Patient Signature: ____________________________________________ Date: ____/____/____ Patient’s Driver’s License #: ___________________________________
