Date ____ / ____ / ____
Date of Birth ______________ Age ________
Are you here because of: AUTO ACCIDENT? Y / N WORK INJURY? Y / N
Please describe your present complaint(s)______________________________________________________
When did it begin?_________________________________________ The onset was: ÿ Sudden ÿ Gradual
Has this occurred before? ÿYes ÿNo If yes, when? _____________________________________________
Is your problem: ÿ Getting Worse ÿ Getting Better ÿ Staying the Same
Have you had chiropractic care in the past? ÿYes ÿNo
If yes, with whom? __________________________________Approx. Date of Last Visit
Primary Care Physician________________________________Approx. Date of Last Visit
Have you seen your medical doctor for this condition? ÿ Yes ÿ No
What, if any other treatments have you tried for this condition?______________________________________
Does anything help decrease your symptoms?____________________________________________________
Check any of these activities that increase you pain:
ÿ Lying Down
ÿ Straining with bowel movement
ÿ Driving in Car
ÿ Rising from a seated position
Are you more irritable due to this condition? ÿYes ÿNo
Have you missed any work due to this condition? ÿYes ÿNo If yes, how long?________________________
Does the pain interfere with your sleep? ÿYes ÿNo
Are you unable to perform any of these activities:
ÿ Yardwork ÿ Recreation _________________ ÿ Cleaning the House ÿ Other_________________
Past Health History
Major Surgeries? ÿYes ÿNo Describe________________________________________________________
Previous Auto Accidents or Injuries_____________________________________________________________
Any Hospitalizations in the past 5 years?_________________________________________________________
Have you ever been diagnosed with any of the following:
High Blood Pressure ÿYes ÿNo
Diabetes ÿYes ÿNo
Stroke, TIA, Heart Disease ÿYes ÿNo
Cancer ÿYes ÿNo
Are you a smoker? ÿYes ÿNo Former smoker? ÿYes ÿNo
Any other health problem not listed?____________________________________________________________
Are you currently taking any medications? ÿYes ÿNo ____________________________________________
ÿ Pain Medication
ÿ Muscle Relaxants
ÿ Blood Pressure Medication
15404 E Springfield Ave Suite 100 Spokane Valley, WA 99037 509.892-9800
Please draw the location of your pain or discomfort on the images below.
Use the symbols shown to represent the type(s) of pain:
D=Dull B=Burning N=Numb S=Sharp/Stabbing T=Tingling C=Cramping
Please rate your current level of pain by circling a number:
0 1 2 3 4 5 6 7 8 9 10No Pain Low Moderate Intense Emergency
Using this scale, over the last 30 days the pain has been: At Worst _________________
At Best __________________ On Average_______________
Patient Privacy Summary
Expires January 1, 2013
We are committed to preserving the privacy of your personal health information. In fact, we are required by law to protect the privacy of your medical information and to provide you with the notice describing: HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION.
We are required by law to have your written consent before we use or disclose to others your medical information for purposes of providing or arranging for your health care, the payment for or
reimbursement of the care that we provide to you, and the related administrative activities supporting your treatment.
We may be required or permitted by certain laws to use and disclose you medical information for other purposes without your consent or authorization.
As or patient, you have important rights relating to inspecting and copying your medical information that we maintain, amending or correcting the information, obtaining an accounting of our disclosures of your medical information, requesting that we restrict certain uses and disclosures of your health information, and complaining if you think your rights have been violated.
We have available detailed Notice of Privacy Policies which fully explains your rights and our obligations under law. We may revise our Notice from time to time. You have the right to receive a copy of the most current Notice in effect. The effective date at the top left hand side of this page indicates our most current Notice in effect. If you have not yet received a copy of our current Notice, please ask the front desk, and we will provide you with a copy.
Printed Name________________________________________ Relationship to Patient___________________________
New regulations and the law require that we have your consent to send you the following items from our office: Newsletters, Gifts, Recall Cards, E-mails, Special Offers, Personal Greetings
¨ YES, you have my permission to send the above listed items to me. ¨ NO, do not send me any of these items.
Before beginning treatment, it is our office policy to inform you of what to expect, possible complications of chiropractic, as well as other forms of treatment. Remember that all forms of treatment (including non-treatment) have associated risks. If you have any questions, please ask the doctor.
The treatment in our office will consist of manipulation of the joints and soft tissues (muscles and ligaments), using the doctor’s hands and/or a mechanical instrument. You may feel movement, and you may hear joint clicks or other noises. Physical therapy methods, including therapeutic exercise, massage and heat or ice may also be used.
Chiropractic treatment is one of the safest methods of treating spinal problems. Still, unexpected problems can occur. Minor, temporary problems such as soreness and stiffness can occur, especially at the start of
treatment. More significant problems, such as fracture of a weakened bone or sprain/disc injuries are rare. A stroke following neck manipulation is an extremely rare complication, occurring less than 1 per million
treatments. Stroke has also been the result of ordinary activities, such as head turning and sneezing.
There are other forms of treatment used by medical doctors. Their risks include:
Medications: Many commonly used medications such as NSAIDs (Advil, Aleve, Ibuprofen) carry risks of tissue damage, including stomach ulcers or kidney damage. This damage can occur quickly and may be irreversible. There are significantly higher risks of developing serious complication with NSAIDs compared with chiropractic. The annual number of hospitalizations for serious GI complications related to NSAIDs is estimated to be at least 103,000. Conservative estimates of NSAID-related deaths in the US is 16,500 per year. New England J Med 1999 Other medications are habit forming, and may mask pain to allow further injury or tissue damage.
Surgery: Surgery is the treatment of choice in less than 1% of back pain patients. Your doctor will and continue to screen you for surgical indicators and will refer you for a surgical opinion if necessary. Clinical results of surgery for simple, mechanical lower back pain have been disappointing and may expose you to unnecessary hospital and medication risks.
Rest/ Non-Treatment: Bed-rest has been shown to increase the likelihood of recurrence of back pain episodes, and make chronic pain more likely. Likewise, non-treatment may cause a permanent mechanical problem to develop, causing future back problems.
Wolf Chiropractic Clinic
15404 E Springfield Avenue Spokane Valley, WA 99037 WHAT TO EXPECT
OTHER TREATMENTS AND RISKS
MOTOR VEHICLE INSURANCE INFORMATION
1. Your Automobile Insurance Company: _________________________________________________ Billing Address: ____________________________________________________________________
Policy Number: _______________________________________________ Claim Number: _______________________________________________
UIM Coverage: ______ Yes ______ No Claim Number:__________________________________ PIP Coverage: ______ Yes ______ No
Agent: ____________________________ Phone:___________________ Fax: _____________ Claims Adjuster: ____________________ Phone:___________________ Fax: _____________ Verified by: ____________________________ Date: _________________
2. Other Automobile Insurance Company: _________________________________________________ Billing Address: _________________________________________________________________
Has Clear Liability Been Established? __________________________________________ Name of Responsible Party: _________________________________________________
Address of Responsible Party: _______________________________________________ Claim Number: ____________________________
Claims Adjuster: ______________________ Phone: ___________________ Fax: _____________ Verified by: ______________________________ Date: _________________
3 . Do you have legal representation? ______ Yes ______ No If yes, with whom?
Name: ________________________________ Phone:_______________ Fax: _______________ Address: _________________________________________________________________________ Case Coordinator: __________________________________________________________________
Verified by: ________________________________ Date: __________________
Patient Name: _________________________________________
Completed by _______________________________________ Date _______________________
Patient Name __________________________________ Date __________________
Date of Injury/Accident _________________________________________________________________
Approximate Location of Auto Accident ____________________________________________________
Type of Collision: ¨ Rear Impact
¨ Head On ¨ Single Car ¨ Roll-Over
Side Impact involving what part of your vehicle?
¨ passenger side ¨ driver’s side ¨ front
Did your car hit anything else after it was hit? ¨ Yes ¨ No If yes, please describe: ____________
Please describe to the best of your knowledge what happened at the time of the accident:
What type of vehicle were you in? Year______________ Make ______________ Model ______________
Where were you seated in the vehicle?
¨ Driver ¨ Front Seat Passenger ¨ Rear Seat Passenger on the: ¨driver’s side ¨passenger side
Were you wearing a seat belt? ¨ Lap belt and shoulder harness ¨ Lap belt Only ¨ None
What direction were you facing at time of impact?__________________________________________
Describe the other vehicle: Year_____________ Make ______________ Model ____________________
Is your vehicle equipped with airbags? ¨ Yes ¨ No Did the airbag(s) deploy? ¨ Yes ¨ No
Were you: ¨ Aware of the impending collision ¨ Caught by surprise
Did you brace for the impact?_____________________________
Did you strike anything within the vehicle? _________________________________________________
If yes, did you have any cuts or visible bruising?_____________________________________
Road Conditions: ¨ Dry ¨ Wet ¨ Ice ¨ Snow ¨ Compact Snow/Ice ¨ Other ________
Time of Day: ¨ Daylight ¨ Dawn ¨ Dusk ¨ Dark
At the time of the accident, your vehicle was:
¨ Stopped ¨ Slowing ¨ Accelerating ¨ Steady Rate of Speed
At the time of the accident, the other vehicle was:
¨ Stopped ¨ Slowing ¨ Accelerating ¨ Steady Rate of Speed
Was your car ¨ drivable or ¨ towed from the scene?
Was the other car ¨ drivable or ¨ towed from the scene?
Were the police or State Patrol notified?_____________ Was anyone cited?__________
AFTER THE ACCIDENT:
Where did you go after the accident?_________________________________________
Mode of Transportation: ¨ you were able to drive yourself ¨ transported by another individual
¨ transported by ambulance
Who was the first doctor you saw after the accident? ____________________________
¨ His/Her Office ¨ ER ¨ Urgent Care
Emergency Department or Urgent Care:
¨ Yes ¨ No Date:_____________ Time:__________
X-rays, CT scans or MRI? ¨ Yes ¨ No
If yes, what body parts were imaged?_____________________________________________________
¨ Yes ¨ No __________________________________________________
Patient Information - Please Print Clearly
E-mail Address __________________________ Patient Name_______________________________ Date of Birth___________________________ Age ____________ Street & Mailing Address_________________________________________ City ________________________________ State__________ Zip ______________ Home Phone ____________________ Cell Phone ______________________
Sex: ÿ Male ÿ Female ÿ Married ÿ Single ÿ Widow(er) ÿ Divorced
Social Security # _______________________ Current Employer _____________________________________________ Department______________________________ Work Phone_______________________ Ok to call at work? Y / N Spouse, Partner or Guardian___________________________________________ Birth Date_____________________ Address (if different) _________________________________________________________________________ Employer_________________________________________ Work Phone_______________________________ Emergency Contact (person not living with patient) _____________________________________________________________ Relationship to Patient__________________________________________ Phone _______________________________ Is this visit because you have you been injured in an accident? ÿ Yes ÿ No Date of Injury? ___________________ If yes, was the accident work related? ÿ Yes ÿ No Was the injury an auto accident? ÿ Yes ÿ No
Have you hired an attorney because of your injury? ÿ Yes ÿ No
If yes: Attorney’s Name ____________________________________________ Phone __________________________ If Work-Related: Employer at time of Injury _________________________________ Phone ___________________ Claim # ______________________________ Other Insurance? ______________________________________________ Please Read Carefully:
Our office bills most insurance carriers. All co-pay and deductible amounts are expected to be paid at the time of your appointment unless other arrangements have been made in advance. Should you have a balance for any reason after your insurance has processed our bill, a statement will be sent to you. It will be your financial responsibility to pay this balance due. Medicare patients please note that examinations and massage therapy performed in this office are not covered by Medicare and most secondary insurances. _________ Patient Initials
I understand that if my insurance company requires a referral, it is my responsibility to obtain this referral from my medical doctor. I also understand that is my responsibility to fully understand my own insurance benefits and that the benefits quoted to me by this office are based on information provided to Wolf Chiropractic Clinic by my insurance carrier. I accept the full responsibility of keeping track of the number of visits allowed and the number of visits used, regardless of where those services have been performed. The information provided to me by this clinic does not guarantee benefits or coverage for services provided by this office. _________ Patient Initials
I have read and understand that if my insurance does not pay in full for the services provided by the health care providers in this clinic, I assume liability for the allowed unpaid portion. I authorize the release of any medical records that might be necessary to facilitate payment of services and authorize the insurance company to make payments direct to the doctors. It is understood that the doctors within this office have access to each other’s records without further authorization, and that my records may be released to other physicians directly involved in my care. _________ Patient Initials
I understand that keeping appointments or canceling them with adequate notice prior to my appointment time is my responsibility. Otherwise, I may be charged a regular office visit fee for missed appointments (“no shows”).