Patient Questionnaire Auto-Collision

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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

Other

Current 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-Time

Marital 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-Time

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Collision- (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

Pedestrian

Automobile 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

Totaled

Other 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

Totaled

Where did the accident happen? Street Names: __________________________________ City/State _____________________________ Was it?

Controlled Intersection

Uncontrolled

Not Intersection

Was there a traffic light?

None

Green

Red

Turn Arrow

Stop Sign Were you:

Slowly Moving

Moving

Stopped

Weather Conditions:

Sunny

Rainy

Cloudy

Street Surface:

Dry

Wet

Slick

Icy

Pavement

Other ______________________ Type of Impact:

Rear end

Front

Side Impact

Roll Over

Brakes on Impact:

Locked Tight

Loosely Applied

Foot not on brake

How 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

Down

Is the car equipped with airbags?

Yes

No Did they deploy?

Yes

No

Did you see the impact coming?

Yes

No Did you brace yourself for impact?

Yes

No

On impact, your head was looking:

Ahead

Behind

Up

Down

To the Right

To the Left

On 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

No

Hospital?

Yes

No Hospital name: _______________________________ How long were you there? _________________________ Taken by ambulance?

Yes

No

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Additional 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

Severe

How often do you experience the pain?

Infrequent

Occasional

Intermittent

Frequent

Constant

What caused the pain? ____________________________________________________________________________________ What increases the pain?

Sitting

Standing

Walking

Running

Lifting

Time on computer

Time on phone

Working overhead

Sleeping

What decreases the pain?

Rest

Ice

Heat

Sleeping

Sitting

Standing

Walking

Stretching How long has the pain been occurring?

Hours

Days

Weeks

Years

Has 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

____________________ ____________________________ ______/______/______

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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

Appetite

Please 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 Disorder

Other: _____________________________________________________

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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 #: ___________________________________

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