Personal Injury Questionnaire
Name ______________________________ Date of Birth _______ Phone __________________ Do you want to be contacted via text:_____ Name of cellphone carrier (ie: T-Mobile):________ Address ____________________________ City ________________ State _______ Zip ______ SSN:______________________________ Weight & Height:___________________________ Dominant hand: ______________________
Employer’s Name ____________________ Employer’s Address _________________________ Your Ins. Co. _________________ _______ Policy # ___________ Agent’s Name ___________ Driver/Other Vehicle ___________ _______ Ins. Co. ___________ Policy # ________________ Have you retained an attorney? ( ) Yes ( ) No Were there any witnesses? ( ) Yes ( ) No
Name(s)______________________ Name(s)______________________ Nature of Accident:
1. Date of Accident: ________________ Time of Day ___________________ 2. Were you: ( ) Driver ( ) Passenger ( ) Front Seat ( ) Back Seat 3. Were you struck from: ( ) Behind ( ) Front ( ) Left side ( ) Right side
4. Were you knocked unconscious? ( )Yes ( )No. If yes, for how long? ________________________ 5. Were police notified? ( ) Yes ( ) No
6. Did you have any physical complaints BEFORE THE ACCIDENT? ( )Yes ( ) No
If yes, please describe in detail: _______________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 7. Please describe how you felt:
a. DURING the accident: ____________________________________________________________ b. IMMEDIATELY AFTER the accident: ______________________________________________ c. LATER THAT DAY _____________________________________________________________ d. THE NEXT DAY: ______________________________________________________________
8. Do you have any congenital (from birth) factors which relate to this problem?
( )Yes ( )No. If yes, please describe: _______________________________________________ ________________________________________________________________________________ 9. Do you have any previous illnesses which relate to this case? __________________ ( ) Yes ( ) No If yes, please describe: ______________________________________________________________ _________________________________________________________________________________
10
.
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 as injuries received.
_________________________________________________________________________________ _________________________________________________________________________________ 11. Where were you taken after the accident? _______________________________________________
12. Have you ever been treated by another doctor since the accident? ( ) Yes ( ) No.
What type of treatment did you receive? _____________________________________________________ _________________________________________________________________________________ 13. Since this injury occurred, are your symptoms: ( ) Improving ( ) Getting Worse ( ) Same
14. CIRCLE SYMPTOMS YOU HAVE NOTICED SINCE ACCIDENT:
Headache Irritability Numbness in Toes Difficulty Sleeping Feet Cold
Neck Pain Chest Pain Shortness of Breath Buzzing in Ears Hands Cold
Neck Stiff Dizziness Fatigue Loss of Balance Stomach Upset
Sleeping Problems Head seems Too Heavy Depression Fainting Constipation
Back Pain Pins & Needles in Arms Lights Bother Eyes Loss of Smell Cold Sweats
Nervousness Pins & Needles in Legs Loss of Memory Loss of Taste Fever
Tension Numbness in Fingers Ears Ring Diarrhea
Symptoms Other Than Above ___________________________________________________________
15. Have you lost time from work as a result of this accident? ( ) Yes ( ) No. If yes, please complete this question.
a. Last Day Worked: ________________________________________________________________ b. Type of Employment: _____________________________________________________________ c. Are you being compensated for time lost from work? ( ) Yes ( ) No.
If yes, please state type of compensation you are receiving? _________________________________ 16. Do you notice any activity restrictions as a result of this injury?( ) Yes ( ) No.
If yes, please describe, in detail: _______________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________
17. Other pertinent information (including disease, surgery, or medical condition): __________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________
I hereby authorize the Doctor to treat my condition as he or she deems. It is understood and agreed the amount paid the Doctor, for x-rays, is for examination only and the x-ray negatives will remain the property of this office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred at this office.
__________________________________ ________________________________
Signature Date
PATIENT CONSENT
FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS
here by states that by signing this Consent, I acknowledge and agree as follows:
1. The Practice's Privacy Notice has been provided to me prior to my signing this Consent. The Privacy Notice includes a complete description of the uses and/or disclosures of my protected health information ("PHI") necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out its health care operations. The Practice explained to me that the Privacy Notice will be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this Consent.
2. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law.
3. I understand that, and consent to, the following appointment reminders that will be used by the Practice: a) a postcard mailed to me at the address provided by me; and b) telephoning my home and leaving a message on my answering machine or with the individual answering the phone, or by e-mail.
4. The Practice may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct its specific health care operations.
5. I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operations. However, the Practice is not required to agree to any restrictions that I have requested. If the Practice agrees to a requested restriction, then the restriction is binding on the Practice.
6. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Practice has already taken action in reliance on this consent.
7. I understand that if I revoke this consent at any time, the Practice has the right to refuse to treat me.
8. I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described to me above and contained in the Privacy Notice, then the Practice will not treat me.
I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand.
__________________________ ___________________________ Name of Patient/Individual (Please print) Signature of Patient/Individual
__________________________ ___________________________ Signature of Legal Representative Relationship to Patient (e.g., Attorney-In-Fact, Guardian, Parent if a minor)
Pain Diagram
Mark the areas on this body where you feel the described sensations.
Use the appropriate symbols. Mark areas of radiation.
Include all affected areas.
Numbness
Pins & Needles
Burning
Aching
Stabbing
- - -
00000
xxxxx
*****
/ / / / /
- - -
00000
xxxxx
*****
/ / / / /
- - -
00000
xxxxx
*****
/ / / / /
Please mark on the pain scale from Zero to 10 the pain you feel with this condition.
10 being the worst pain you have felt with this condition.
Pain Chart
Neck-Shoulder-Arm-Pain
On a scale of zero to 10, I rate my discomfort as follows:
(___________________)
0 10 no pain severe pain
Mid Back Pain
On a scale of zero to 10, I rate my discomfort as follows:
(___________________)
0 10 no pain severe pain
Low Back and Leg Pain
On a scale of zero to 10, I rate my discomfort as follows:
(___________________)
0 10 no pain severe pain
NOTICE OF DOCTOR’S LIEN
Patient:Date of Accident:
I do hereby authorize Richard Huston, DC to furnish you, my attorney, with full report of his examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was recently involved.
I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums as my be due and owing him for medical service rendered me both by reason of this accident and by reason of any other bills that are due his office and to withhold such sums from any settlement, judgment or verdict which may be paid to you, my attorney, or myself, as the result of the injuries for which I have been treated or injuries in connection therewith.
I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service rendered me and that this agreement is made solely for said doctor’s additional protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, judgment or verdict by which I eventually recover said fee.
I agree to promptly notify said doctor of any change or addition or attorney(s) used by me in connection with this accident, and I instruct my attorney to do the same and to promptly deliver a copy of this lien to any such substituted or added attorney(s).
Please acknowledge this letter by signing below and returning to the doctor’s office. I have been advised that if my attorney does not wish to cooperate in protecting the doctor’s interest, the doctor will not await payment but may declare the entire balance due and payable.
Date
Patient Signature
The undersigned being attorney of record for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict, as may be necessary to adequately protect and fully compensate aid doctor above-named. Attorney further agrees that in the event this lien is litigated that the prevailing party will be awarded attorney fees and costs.
Date
Attorney’s Signature
Please date, sign and return one copy to doctor’s office. Also keep one copy for your records.
Doctor Signature
Richard Huston, DC Randall Lindstrom, DC 1150 Hungry Neck Blvd. Suite D
Mt. Pleasant, SC 29464 843-884-1876
