New Auto Patient Intake Form

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Phone: 303-445-2225 | www.DenverChiropracticLLC.com |Fax: 303-433-3177 Dr. Trent Artichoker | Dr. Nick Shupe | Dr. Brittany Downing

New Auto Patient Intake Form

Patient Information

Name_______________________________Date of Birth ________Date_________Date of Accident________ Address_______________________________________City/State______________________Zip___________ Phone ____________________Email Address (for clinic news)______________________________________ Gender________________Marital Status________________________#Children_______________________ Occupation_______________________Company Name___________________Work Phone______________ Spouse/Gaurdian’s Name_____________________________________Occupation_____________________ Contact Name, In Case of Emergency_______________________________Phone______________________

Your Auto Insurance

Insurance Company__________________________________________Policy#_________________________ Insured’s Name__________________________________MedPay Claim #_____________________________ Adjustor’s Name________________________________________Phone#_____________________________

Assignment of Benefits | Release of Records

I authorize my primary auto insurance company or tertiary auto insurance company to make payments to Denver Chiropractic, LLC for all services provided by Denver Chiropractic, LLC. I give permission for my doctors and any holder of my medical records to be released by Denver Chiropractic, LLC. I will provide all information needed to process my claims in a timely manner.

Signature_________________________________________________________________________________

At-Fault Auto Insurance

Insurance Company__________________________________________Policy#_________________________ Insured’s Name_________________________________________Claim #_____________________________ Adjustor’s Name________________________________________Phone#_____________________________

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3890 Federal Blvd Unit 1 | Denver, CO |80211

History of Accident

1. Location of Accident City/State___________________________Street/s____________________________ 2. Approx. Time of Day______________Weather Conditions?__________________Seat Belt On?__________ 3. Any Passengers?________Names____________________________________________________________ 4. Year/Make/Model of Your Vehicle_________________________Other Vehicle_______________________ 5. Your Approx. Speed at Impact?____________________________Other Vehicle______________________ 6. Your Head Position at Impact?(turned L/R, up/down)____________You Aware of Impending Impact?_____ 7. Drivers Feet Position at Impact? (brake, clutch, both, gas, etc.)____________________________________ 7. Witness Names?__________________________________Photographs Taken?______________________ 8. What Part of Your Car Was Damaged?______________________________Their’s____________________ 9. Description of the Accident 10. Diagram of the accident

_________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________

11. Cost of Repairing Your Car_________________

12. Did either insurance company refer you to the place where you got the estimate?___________________ 13. Were you paid for the vehicle damage?________How much?__________

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History of Accident Cont.

14. Did the Police Arrive?___________Which Police Department?___________________________________ 15. Police Officer’s Name___________________________Was Anyone Cited?_________________________ 16. Statements made by you or others at the scene_______________________________________________ _________________________________________________________________________________________ 17. Have you made statements to any insurance company or anyone else?____________________________ _________________________________________________________________________________________ 18. Were any vehicles towed away from the scene?_______Which Vehicle?___________________________ 19. Name of Other Driver_____________________________Phone#_________________________________ 20. Date of Birth_________________Was This a Company Vehicle?______Which?______________________ 21. Drivers License #__________________Vechile License #______________________

22. Driver’s Address________________________________________________________________________ 23. Damage to the other drivers car?_______Describe_____________________________________________ _________________________________________________________________________________________ 24. Do you believe that any of the following were defective and resulted in either the accident itself or a worsening of your injuries? (road signs, roads, traffic signal, brakes, seat belt, airbags, seat,etc.)___________

Injuries,Impairments, & Damages

Injuries, impairments as a result of your accident?_______________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

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Injuries,Impairments, & Damages Cont.

Which of the following do you suffer from now, which you did not prior to the accident:

__Headaches __Dizziness __Difficulty Concentrating

__Long Term Memory Loss __Short Term Memory Loss __Amnesia

__Loss of Consciousness at Scene __“Blackouts” Since Collision __Forgetting ATM or other Numbers

__Reading Problems __Writing Problems __Typing Problems

__Apathy __Irritability __Sleep Disturbances

__Personality Changes __Emotional Difficulties __Relationship Difficulties __Blurred Vision __Photophobia (Sensitivity to Light) __Vision Changes

__Intolerance to Alcohol __Intolerance to Heat __Intolerance to Cold

__Impaired Comprehension __Impaired Learning __Attention Impairment

__Loss of Libido __Missing Periods of Time __Speech Difficulties

__Concussion in Collision __Nausea __Vomiting

__Extreme Thirst Since Collision __Fatigue __Menstrual Irregularities

__Tinnitus (Ringing of Ears) __Noise Intolerance __Loss of Coordination

__Bumping Into Objects in View __Loss of Balance __Fluid in Ears

__Hearing Loss __Vertigo (Spinning Sensation) __Increased Symptoms in Crowds

__Anxiety __Depression __Change in Personality

__Flashbacks to Accident Scene __Intrusive Thoughts of Accident __Nightmares Since Collision __Unusual Behavior Since Collision __Social Withdrawal __Panic Attacks

__Thoughts of Death /Suicide __Weight Loss / Gain _______lbs __Loss of Taste / Smell

__Blackouts with Neck Movements __Dizziness with Neck Movements __“Clunk” Sound w/ Moving Neck

__Jaw Pain __Clicking in Jaw __Pain with Chewing

Numbness / tingling / weakness in arms? Yes No R L Level(s)__________________________ Numbness / tingling / weakness in legs? Yes No R L Level(s)__________________________ Did the Seatbelt bruise you?_______Where?________

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Injuries,Impairments, & Damages Cont.

Where was headrest located before impact? __Upper Back __Mid Neck __Mid Head __Upper Head __None

Did your head or body strike anything inside the car? __Yes __ No If so, what?_________________________ Did you lose consciousness? __Yes __No Did items in the car get displaced?What?___________________ Did your Airbag(s) Deploy? __Yes __No Did your seats break? __Yes __No

Ambulance Companies:

Company Date From To

1._______________________________________________________________________________________ 2._______________________________________________________________________________________ Emergency Room, Hospitalizations, Outpatient Surgeries (Related only to this Collision):

Physician Facility When Problems

1._______________________________________________________________________________________ 2._______________________________________________________________________________________ 3._______________________________________________________________________________________ 4._______________________________________________________________________________________ Treating Physicians / Specialists / Therapists (Related only to this Collision):

Provider Facility Address Phone

1._______________________________________________________________________________________ 2._______________________________________________________________________________________ 3._______________________________________________________________________________________ 4._______________________________________________________________________________________ 5._______________________________________________________________________________________ What are you not able to do anymore as a result of this accident?___________________________________ _________________________________________________________________________________________

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Injuries,Impairments, & Damages Cont.

Impaired Activities

Circle all activities which have been impaired in any way by the accident in question:

Daily Activities

bathing/showering bending brushing teeth Dressing driving car

vacationing dining out movie going standing sitting

sexual relations lifting church events child care

religious activities (bending/kneeling)

shampooing hair eating Moving reading shaving

shopping watching TV sleeping traveling social events

Domestic Activities (Activities within the Home)

Bending Cooking ironing housecleaning laundry

Washing Dishes vacuuming dusting interior painting decorating

Household Activities (Activities outside the Home)

Trimming bushes Gardening Tree trimming Mowing Lawn Yard Work Exterior painting Car Washing Landcaping House Maintenence Farm activities

Work Activities

Sitting standing lifting using telephone computer work

Reading bending typing writing child care

Hobby Activities

Aerobic exercise archery backpacking bowling badminton

baseball basketball basketry bicycling Boxing

card playing camping dancing fencing Fishing

flying football gardening golf Handball

gymnastics health clubs hockey hunting Judo

horseback riding ice skating Karate painting Yoga

jogging/running photography raquetball rafting sailing

mountain climbing sewing snow skiing swimming walking

musical instruments volleyball water skiing water sports weight lifting

Activities which you have performed despite pain, due to financial, family or personal needs (Duties Under Duress):

__Work __Education __Domestic (Activities within the Home) __Household (Duties outside the Home) _________________________________________________________________________________________ Past Motor Vehicle Accidents, Workers Compensation Claims, or other claims of Any Sort:________________

______________________________________________________________________________

____________

______________________________________________________________________________

____________

______________________________________________________________________________

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List Injury in Order of Importance Is the pain constant?(Y/N). If not, Rate with 0 to 10 scale (10 being the worst) the Describe what the pain feels Getting Worse(i.e. neck, left shoulder, headache). what % of the day does it affect you. least amount pain, avg. pain, and max pain level. like (achy, stabbing, etc.) or better?

1._____________________ ________________ ________ ________ ________ ________________ _________ 2._____________________ ________________ ________ ________ ________ ________________ _________ 3._____________________ ________________ ________ ________ ________ ________________ _________ 4._____________________ ________________ ________ ________ ________ ________________ _________ 5._____________________ ________________ ________ ________ ________ ________________ _________ 6._____________________ ________________ ________ ________ ________ ________________ _________ 7._____________________ ________________ ________ ________ ________ ________________ _________

Condition # What Makes it Worse?(dishes, getting dressed, driving, etc.) What Makes it Better?(stretching, not moving, heat, pills, etc.) 1. _______________________________________________ _______________________________________________ 2. _______________________________________________ _______________________________________________ 3. _______________________________________________ _______________________________________________ 4. _______________________________________________ _______________________________________________ 5. _______________________________________________ _______________________________________________ 6. _______________________________________________ _______________________________________________ 7. _______________________________________________ _______________________________________________

List Allergies______________List Current Presciptions____________________________________ Current Over The CounterMedications____________________________

Please describe your auto related injuries, list the worst injury first and the least impairing injury last.

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Past Medical History

Personal Physician (Name)___________________________________________________________________ Phone:________________________Address:____________________________________________________ Please list all other past doctors or other health care providers (medical and alternative) you have seen and include their addresses, the dates or time periods in which you saw them, the reasons for seeing them, the types of treatment given to you, and whether they might have any information that would help us compare your present health with your health before the collision. (Excluding those noted above.)

1._______________________________________________________________________________________ 2._______________________________________________________________________________________ 3._______________________________________________________________________________________ 4._______________________________________________________________________________________ 5._______________________________________________________________________________________ List, as carefully and accurately as you can, all injuries, illnesses, or medical conditions you have had in your life, even if they have no similarity to the injuries that you received in this collision. Include the approximate dates, the cause of the injuries, the doctors who treated you, and whether you fully recovered from these problems. If any lawsuit or claim was made for any of those injuries please so state.

_________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Family Health History (circle any that apply) auto-immune, spine problems, arthritis, cancer, diabetes, heart disease,

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I understand and have read the consent to treatment and examination, our privacy policy, and information regarding your healing.

Signature ________________________________________________________________Date_____________

Consent to Examination & Treatment

I hereby request and consent to the performance of chiropractic examinations, adjustments, dry needling, graston technique, active release technique, flexion-distraction therapy, moist heat, electrotherapy, ultrasound, kinesio taping, and other procedures on me (or the patient named below, for whom I am legally responsible) by the licensed doctors at Denver Chiropractic, LLC. I understand and I am informed that, in the practice of chiropractic that there are some risks to examination and treatment including, but not limited to, soreness, fractures, disc injuries, strokes, dislocations, sprains, pneumothorax, increased symptoms, or no improvement. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known, is in my best interest. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatments. I intend this consent form to cover the entire course of treatment of my present condition and for any future conditions for which I seek treatment. I understand that I may refuse treatment at any time and that I am responsible for my healthcare choices

Our Privacy Policy

The office of Denver Chiropractic, LLC is committed to upholding the security and confidentiality of personal information that you provide to us. We take our responsibility of safeguarding your information very seriously. We do not share or sell patient

information with anyone outside our office without your written consent. This policy covers information including personal, financial, or health information about a consumer or customer relationship. I hereby authorize that my records of evaluation and treatment with the office of Denver Chiropractic, LLC may be forwarded to referring physicians, specialists, or therapists who are also involved in my healthcare.

Regarding Your Healing

1. Auto injuries produce wide spread damage and thus take more visits then an average case of non-auto related acute neck or back pain. On average, a typical whiplash injury will require approximately 26 visits for resolution of the injuries. Everyone responds to treatment slightly different which may shorten or lengthen the amount of total visits needed.

2. Neck or back pain usually fluctuates, meaning that you will have flare ups along the course of your healing. It is expected to have aggravations of your injuries.

3. If you have never been adjusted you may be sore after your treatment. This soreness is similar to a long hike or a good workout type of soreness. Soreness can be a good response, as is the soreness you get after a good workout.

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3890 Federal Blvd Unit 1 | Denver, CO |80211 Neck Disability Index

Pain Intensity (Circle One) A. I have no pain at the moment. B. The pain is very mild at the moment.

C. The pain is very moderate at the moment. D. The pain is fairly severe at the moment. E. The pain is very severe at the moment. F. The pain is the worst imaginable at the moment.

Personal Care- Washing, Dressing etc (Circle one)

A. I can look after myself normally, without causing extra pain. B. I can look after myself normally, but it causes extra pain. C. It is painful to look after myself, but I am slow and careful. D. I need some help but manage most of my care.

E. I need help everyday with every aspect of my self-care. F. I do not get dressed, I wash with difficulty and I stay in bed.

Lifting (Circle One)

A. I can lift heavy weights without extra pain. B. I can lift heavy weights, but it causes extra pain.

C. Pain prevents me from lifting heavy weights off the floor, but can lift if they are conveniently positioned such as a table. D. Pain prevents me from lifting heavy weights but I can manage light/medium weights if they are conveniently positioned.

E. I can only lift light weights.

F. Pain prevents me from lifting weight from the floor.

Reading (Circle One)

A. I can read as much as I want to with no pain in my neck. B. I can read as much as I want to with slight pain in my neck. C. I can read as much as I want with moderate pain in my neck. D. I can’t read as much as I want because of the moderate pain in my neck.

E. I can hardly read at all because of the severe pain in my neck.

F. I cannot read at all.

Headaches (Circle one)

A. I have no headaches at all.

B. I have slight headaches, which come in-frequently. C. I have moderate headaches, which come in-frequently. D. I have moderate headaches, which come frequently. E. I have severe headaches, which come frequently F. I have headaches almost all the time.

Date_____________

Concentration (Circle One)

A. I can concentrate fully when I want to with no difficulty.

B. I can concentrate fully when I want to with slight difficulty. C. I have a fair amount of difficulty when concentrating.

D. I have a lot of difficulty in concentrating when I want to. E. I have a great deal of difficulty in concentrating when I want to.

F. I cannot concentrate at all.

Work (Circle one)

A. I can do as much work as I want to. B. I can only do my usual work, but no more. C. I can do most of my usual work, but no more. D. I cannot do my usual work. E. I can hardly do any work at all. F. I can’t do any work at all.

Driving (Circle one)

A. I can drive my car without any neck pain.

B. I can drive my car as long as I want with slight neck pain. C. I can drive my car as long as I want with moderate neck pain. D. I can’t drive my car as long as I want because of moderate pain in my neck.

E. I can hardly drive at all because of severe pain in my neck. F. I can’t drive my car at all.

Sleeping (Circle one)

A. I have no trouble sleeping. B. My sleep is slightly disturbed.

C. My sleep is mildly disturbed (1-2 hours sleepless). D. My sleep is greatly disturbed (2-3 hours sleepless). E. My sleep is greatly disturbed (3-5 hours sleepless). F. My sleep is completely disturbed (5-7 hours sleepless).

Recreation (Circle one)

A. I am able to engage in all of my recreation activities with no neck pain at all.

B. I am able to engage in all of my recreational activities, with some neck pain.

C. I am able to engage in most, but not all of my usual activities because of neck pain.

D. I am able to engage in a few of my activities because of pain in my neck.

E. I can hardly do any of my recreational activities because of pain in my neck.

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Low Back Disability Index

Pain Intensity (Circle one)

A. The pain comes and goes and is very mild. B. The pain is mild and does not vary much. C. The pain comes and goes and is moderate. D. The pain is moderate and does not vary much. E. The pain is severe but comes and goes. F. The pain is severe and does not vary much.

Personal Care (Circle one)

A. I would not have to change my way of washing or dressing in order to avoid pain.

B. I do not normally change my way of washing or dressing even though it causes some pain.

C. Washing and dressing increase the pain, but I manage not to change my way of doing it.

D. Washing and dressing increase the pain and I it necessary to change my way of doing it.

E. Because of the pain, I am unable to do any washing and dressing without help.

F. Because of the pain, I am unable to do any washing or dressing without help.

Lifting (Circle one)

A. I can lift heavy weights without extra pain. B. I can lift heavy weights, but it causes extra pain.

C. Pain prevents me from lifting heavy weights off the floor.

D. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, e.g. on the table. E. Pain prevents me from lifting heavy weights , but I can manage light to medium weights if they are conveniently positioned.

F. I can only lift very light weights, at the most.

Walking (Circle one)

A. Pain does not prevent me from walking any distance. B. I have some pain with walking but it does not increase with distance.

C. Pain prevents me from walking more than one mile. D. Pain prevents me from walking more than 1/2 mile. E. I can only walk while using a cane or on crutches.

F. I am in bed most of the time and have to crawl to the toilet

Sitting (Circle one)

A. I can sit in any chair as long as I like without pain. B. I can only sit in my favorite chair as long as I like. C. Pain prevents me from sitting more than one hour. D. Pain prevents me from sitting more than 1/2 hour. E. Pain prevents me from sitting more than ten minutes. F. Pain prevents me from sitting at all

Date____________ Standing (Circle one)

A. I can stand as long as I want without pain.

B. I have some pain while standing, but it does not increase with time. C. I cannot stand for longer than one hour without increasing pain. D. I cannot stand for longer than 1/2 hour without increasing pain. E. I can't stand for more than 10 minutes without increasing pain. F. I avoid standing because it increases pain right away

Sleeping (Circle one) A. I get no pain in bed.

B. I get pain in bed, but it does not prevent me from sleeping. C. Because of pain, my normal night's sleep is reduced by less than one-quarter.

D. Because of pain, my normal night's sleep is reduced by less than one-half.

E. Because of pain, my normal night's sleep is reduced by less than three-quarters.

F. Pain prevents me from sleeping at all.

Social Life (Circle one)

A. My social life is normal and gives me no pain.

B. My social life is normal, but increases the degree of my pain. C. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc.

D. Pain has restricted my social life and I do not go out very often. E. Pain has restricted my social, life to my home.

F. Pain prevents me from social, life at all.

Traveling (Circle one) A. I get no pain while traveling.

B. I get some pain while traveling, but none of my usual forms of travel make it any worse.

C. I get extra pain while traveling, but it does not compel me to seek alternative forms of travel.

D. I get extra pain while traveling which compels me to seek alternative forms of travel.

E. Pain restricts all forms of travel.

F. Pain prevents all forms of travel except that done lying down.

Changing Degree of Pain (Circle one)

A. My pain is rapidly getting better.

B. My pain fluctuates, but overall is definitely getting better. C. My pain seems to be getting better, but improvement is slow at present.

D. My pain is neither getting better nor worse. E. My pain is gradually worsening.

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Provider Lien

TO: Denver Chiropractic, LLC

FROM: ___________________________ (Print Patient Name)

I hereby authorize and direct my attorney/tertiary insurance company, to pay directly to said health provider such sums as may be due and owing it for medical services rendered me by reason of my accident on ________________(date of accident) and to withhold such sums from the net proceeds of any settlement, judgment or verdict as may be necessary to adequately protect said health provider. Net proceeds means the gross amount recovered, less any attorney fees and costs. In exchange for receiving this lien, said health provider agrees to forego further collection efforts. I hereby further give a lien on my case to said health provider against any and all net proceeds of 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 further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee. This lien shall be irrevocable and shall be valid and enforceable out of the net proceeds of my settlement, judgment or verdict. I understand that if I discharge my attorney, I have an obligation to notify said health care provider in writing within 48 hours.

Please initial all statements below:

_____ I understand that I will be charged the full usual and customary prices for my medical care and not cash pay or insurance rates. I further understand that this is the amount I am expected to repay the provider. I further agree that this amount is reasonable. _____ I agree that if, at any time, including prior to settlement, the provider finds it necessary to proceed against the patient to collect medical bills, the provider may do so.

_____ In the event of the receipt of funds and non-payment resulting in the institution of lien enforcement proceedings, I shall be responsible for the payment of all reasonable fees and costs, including attorney’s fees incurred by my medical providers in enforcing said lien.

_____ I fully understand that I am directly and fully responsible to said health provider for all medical bills submitted for services rendered me and that this agreement is made solely for said health provider’s additional protection and in consideration of awaiting payment.

___________ _______________________ ______ Date [PATIENT NAME]

We, the health provider, agree to the terms stated above. _________________________________________________

By: Denver Chiropractic, LLC / Owner: Dr. Trent Artichoker ___________