Name:________________________________________________________________Gender: ○ Male ○ Female Address:_____________________________________________________________________________________ City:__________________________________________State:______________________Zip:_________________ Home Number:_____________________Work Number:___________________Other Number:________________ Email Address:________________________________________________________________________________ Date of Birth(MM/DD/YYYY)_____________________________ Age:________
Marital Status: ○ Single ○ Married ○ Other If married please provide spouses name:_________________________ If Patient Is a Minor, Name of Parent(s):_____________________________________________________________ Primary Care Physician:__________________________________________________________________________
Name:_______________________________________Relationship to Patient:____________________ Contact Number:_____________________________________________________________________
How Did You Hear About Us?(please check all that apply)
○ Google ○ Yelp ○ Bing ○ CitySearch ○ Facebook ○ Chamber of Commerce ○ Walk/drive by ○ Chicks Connect ○ Referred by:____________________________________ ○ Insurance Website:______________________ ○ Local Event:____________________________________ ○ Other:________________________________
Auto Insurance Company:__________________________________________________________________________ Insurance Co. Phone #: _______________________________ Claim #: _____________________________________ Claims Adjuster:_________________________________________________________________________________ Insurance Co. Address:____________________________________________________________________________ Have you retained an attorney? ○ Yes ○ No
Impact / Seat Belt/ Head Rest / Head / Body Position
Describe in your own words what happened to you upon impact:_______________________________________________ ___________________________________________________________________________________________________ ○ Yes ○ No Did you see the accident coming?
○ Yes ○ No Did you brace for impact?
○ Yes ○ No Did you have your hands on the steering wheel at impact? Head/Body position at the time of impact:
Head: ○ Straight ○ Turned right ○ Turned left
Body: ○ Straight ○ Turned right ○ Turned left
At the time of the accident, what parts of your head/body hit what parts of the inside of the vehicle:__________________ ___________________________________________________________________________________________________ ○ Yes ○ No Were you wearing glasses, a hat, or dentures? Where were they after the accident?__________________ ○ Yes ○ No Were seat belts worn? ○ Yes ○ No Were shoulder harnesses worn?
○ Yes ○ No Does your vehicle have air bags? ○ One ○ Two ○ Other_________________ ○ Yes ○ No Did your airbags release? ○ One ○ Both ○ Other_________________
○ Yes ○ No Does your vehicle have headrests? If yes, what was its position compared to your head before the crash? Top of headrest even with: ○ Middle of neck ○ Top of head ○ Bottom of head ○ Yes ○ No Was your vehicle moving at the time of the accident? ○ Slowing down ○ Speeding up ○ Constant
What was the speed limit on the road you were traveling?______________ Mph
Ability to Move Body
Where were you in the vehicle prior to the accident?________________________________________________________ After the accident?______________________________________________________________________ As a result of the accident, were you:
○ Rendered unconscious ○ Dazed, situation vague ○ Shaken up but could function ○ Yes ○ No Could you move all parts of your body? If no, what parts and why not?_____________________________ ___________________________________________________________________________________________________ ○ Yes ○ No Were you able to get out of the vehicle? If no, why not?_________________________________________
Automobile Accident History
Date of accident:____________________________________ Time:_________________ ○ AM ○ PM
Driver of vehicle:__________________________________ Where were you seated?_______________________________ Vehicle’s owner:____________________________ Year and model of vehicle you were in:__________________________ Year and model of the other vehicle(s) in collision:___________________________________________________________ Number of vehicles in collision: ○ 1 ○ 2 ○ 3 ○ Other:___________ Number of people in your vehicle:_____________ Where did the accident occur?__________________________________________________________________________
Visibility at the time of the accident: ○ Poor ○ Fair ○ Good
Road Conditions at the time of the accident: ○ Icy ○ Rainy ○ Wet ○ Clear ○ Dark ○ Other:____________ Your vehicle: ○ Hit another vehicle -or- ○ Was hit in the: ○ Right side ○ Left side ○ Rear ○ Front Type of accident: ○ Head-on collision ○ Broad-side collision ○ Rear-end collision ○ Single vehicle collision
○ Front-impact, rear-ended vehicle in front ○ Other (explain):__________________________ Were the internal vehicle parts broken? ○ Yes ○ No
Symptoms from Accident
○ Yes ○ No Did you receive any bruises from the seat belts? If so, where?______________________________________ ○ Yes ○ No Did you receive any other bleeding cuts or bruises? If cut, where?__________________________________
If bruises, where?_________________________________________________________________________ Please describe how you felt. PLEASE BE SPECIFIC
Immediately after the accident:____________________________________________________________________ Later that ○ Day ○ Night:__________________________________________________________________________ The next day(s):_________________________________________________________________________________
General Systems Update
Check symptoms that have become apparent since the accident/injury:
○ Nervousness ○ Face flushed ○ Shortness of breath ○ Cold feet ○ Fainting
○ Neck pain/stiffness ○ Ringing/buzzing ears ○ Head seems too heavy ○ Chest pain ○ Anxiety
○ Midback pain ○ Loss of balance ○ Irritability ○ Constipation ○ Seizures
○ Low back pain ○ Loss of smell ○ Depression ○ Diarrhea ○ Visual disturbances
○ Eyes sensitive to light ○ Loss of taste ○ Sleeping trouble ○ Fatigue ○ Forgetfulness
○ Pain behind eyes ○ Loss of memory ○ Toe numbness ○ Tension ○ Blurred vision
○ Dizziness ○ Pins & needles - arms ○ Finger numbness ○ Fever ○ Double vision
○ Cold sweats ○ Pins & needles - legs ○ Cold hands ○ Headache ○ Confused/Disoriented ○ Other:________________________________________________________________________
○ Yes ○ No Did you seek medical help immediately after the accident? If yes, how did you get there? ○ Someone else drove me ○ Drove own vehicle ○ Police ○ Ambulance
Doctor/Hospital/Clinic:_______________________________________ Date of first visit:_______________ ○ Yes ○ No Were you examined? ○ Yes ○ No Were x-rays taken?
What diagnosis did the doctor give you?:______________________________________________________ ○ Yes ○ No Were you given treatment? If so, what type?___________________________________________________ What benefits did you receive from treatment?_________________________________________________ _______________________________________________________________________________________ Date of last treatment:___________________________________________
○ Yes ○ No Did the doctor refer you to another health professional? If yes, to who and for what?___________________ _______________________________________________________________________________________ ○ Yes ○ No Did you follow the recommendation? If no, why not?____________________________________________
Doctor/Clinic:_______________________________________________________ Date of first visit:____________________ ○ Yes ○ No Were you examined? ○ Yes ○ No Were x-rays taken?
Work Status History
Occupation:_______________________________________ Employer:__________________________________________ ○ Yes ○ No Have you missed time from work? If no, who told you to return?:_________________________________
If yes, ○ Off work full-time Dates:_____________________________________________________ ○ Off work part-time Dates:_____________________________________________________ ○ Unable to return to work since the accident.
What type of physical activity is required at work:___________________________________________________________ ○ Yes ○ No Is there alternative work available?
Prior Similar Symptoms
○ Yes ○ No Did you have any physical complications just before the accident? If yes, please describe in detail:_______ _____________________________________________________________________________________ _____________________________________________________________________________________ ○ Yes ○ No Prior to this accident, have you had any similar symptoms? If yes, please explain (falls, injuries, etc.):_____ _____________________________________________________________________________________ _____________________________________________________________________________________ ○ Yes ○ No Have you been in accidents prior to this one? If yes, when______________ Where?__________________ How was it treated?_____________________________________________________________________ Result of being treated:__________________________________________________________________ ○ Yes ○ No Are you now being treated?
I do hereby authorize Milwaukie Spine and Sport, LLC to furnish you, my attorney and/or insurance
carrier, with information regarding the accident in which I was involved.
I understand that I am directly responsible to Milwaukie Spine and Sport, LLC for any and all bills
submitted for services. I further understand that such payment is not contingent on any settlement,
judgment or verdict by which I may eventually recover said fee. In consideration of not having to
immediately pay debt, I hereby assign and convey to Milwaukie Spine and Sport, LLC a legal and equitable
interest in any and all causes of action of rights of recovery. I also understand that a nine percent interest
charge will be accrued to any balance held over ninety days until my balance is zero.
I hereby authorize my attorney, and insurance company to pay directly to Milwaukie Spine and Sport, LLC,
that which is owing for professional services as a result of this accident and by reason of any other bills
that are due to Milwaukie Spine and Sport, LLC including attorney fees. These are to be withheld from
any settlement or judgment I hereby further give a lien on my case to Milwaukie Spine and Sport, LLC
against any and all proceeds of my settlement, judgment or verdict which may be paid to you as result of
the injuries for which I have been treated.
I further instruct a separate check to be issued to Milwaukie Spine and Sport, LLC for services rendered.
I have read this document, I understand it, and I voluntarily agree to be bound by it. I am directing my
attorney to protect Milwaukie Spine and Sport, LLC interest as provided herein.
Patient Name (PRINT)
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
adequately to protect the said doctor named above.
Patient Privacy Notice
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 your medical information for other purposes without your consent or authorization.
• As our patient, you have important rights relating to inspecting and copying your medical information that we maintain; amending or correcting that information.
• We have available a detailed Notice of Privacy Practices handout at the front desk if you would like further details.
“I hereby authorize Milwaukie Spine and Sport, LLC to make use and disclosure of my protected health
information (information in my medical and/or financial records) as indicated below.”
Patient's Name:___________________________________________ Date: _______________ Signature of Patient or Guardian:_____________________________________________
I __________________________hereby give consent to Milwaukie Spine and Sport, LLC to access information concerning my selected records.
○ Financial/ Insurance ○ Medical
○ Other (specify) ____________
Signature of Patient:__________________________________________ Date:_________________
Group Practice Privacy Notice
Milwaukie Spine and Sport, LLC is a multi-practitioner office, and on occasion, your treatment may be provided by another doctor due to illness, vacation, time conflict, etc. In order to provide the best care to patients, it may be necessary to discuss health information in a private setting (away from other patients) in order to update other practitioners in the office of a patient's status.
By signing this form you acknowledge that you have been made aware and accept that your health information may be discussed among the practitioners.