Motor Vehicle Accident Intake Form

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About You

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:__________________________________________________________________________

Emergency Contact

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:________________________________

Insurance Information

Auto Insurance Company:__________________________________________________________________________ Insurance Co. Phone #: _______________________________ Claim #: _____________________________________ Claims Adjuster:_________________________________________________________________________________ Insurance Co. Address:____________________________________________________________________________ Have you retained an attorney? ○ Yes ○ No

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Patient Name:___________________________________

Today' Date:__________________

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

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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:________________________________________________________________________

First Doctor/Hospital/Clinic

○ 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?____________________________________________

Second Doctor/Clinic

Doctor/Clinic:_______________________________________________________ Date of first visit:____________________ ○ Yes ○ No Were you examined? ○ Yes ○ No Were x-rays taken?

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Patient Name:___________________________________

Today' Date:__________________

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?

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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.

________________________________

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Patient Name (PRINT)

Patient Signature

Date

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.

_________________________________ ___________________________________

_____________

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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:_____________________________________________

RECORDS RELEASE

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.

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I hereby request and consent to the performance of chiropractic adjustments and other chiropractic

procedures, including various modes of physical therapy, on me (or on the client named below, for whom

I am legally responsible) by the doctors of chiropractic and at Milwaukie Spine and Sport, LLC and/or

other licensed doctors of chiropractic who now, or in the future, treat me while employed by, working or

associated with or serving as back-up for the chiropractic physicians of Milwaukie Spine and Sport, LLC.

I have had an opportunity to discuss with the doctor of chiropractic, and/or with other office or clinic

personnel at Milwaukei Spine and Sport, LLC the nature and purpose of chiropractic adjustments and

procedures. I understand and am informed that, as with all healthcare treatments, results are not

guaranteed.

I further understand and I am informed that, as is with all healthcare treatments, in the practice of

chiropractic there are some risks to treatment, including but not limited to, muscle spasms for short

periods of time, aggravating and/or temporary increase in symptoms, lack of improvement in symptoms,

fractures, disc injuries, strokes, dislocations and sprains. 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 doctors feels at the time, based upon the facts then known,

is in my best interest.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions

about its content, and by signing below I agree to the above-named procedures. I intend this consent

form to cover the entire course of treatment for my present condition and for any future condition(s) for

which I seek treatment.

Patient's Name:___________________________________________ Date:_________________________

Signature of Patient or Guardian:____________________________________________________________

Consent for Treatment of a Minor

I (we) being the parent or guardian of ____________________________________________ ,a minor, the

age of ____do hereby consent, authorize and request Dr. ______________________________________

to administer such treatment deemed advisable, necessary or requested on the above minor.

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Financial Policy

1. Responsibility for Payment: We consider the patient to be responsible for payment of services. In cases

where the patient is a minor, the parent that the child is living with is responsible for payment.

2. Insurance Billing: As a courtesy to you, we will bill your primary insurance company provided that the

pertinent identification numbers are provided. It is the patient’s responsibility to inform our office of ANY

insurance changes.

3. Auto Insurance: If patient is involved in an automobile accident, the responsible party is the insured

automobile the patient was in at the time of the accident. The patient is required by this office to fill out

and sign all lien agreements.

4. Major Medical Insurance: Please see the following regarding major medical insurance:

□ If your annual insurance deductible has not yet been met, payment is expected at the time of

service.

□ Insurance is considered to be a private contract between the patient and insurance company: it is

the patient’s responsibility to resolve any difficulties with claims processing directly with the

insurance company. We will call for benefits, but there is NO GUARANTEE OF BENEFITS.

5. Workers Compensation: If an injured worker has completed the appropriate forms in our office, we will

bill his/her industrial accident insurance.

6. All Insurance Claims: Any amount not covered by major medical insurance, auto insurance, workers

compensation insurance is the FULL RESPONSIBILITY of the patient or patient’s guardian.

7. Supplements, supports, etc: All supplements and other supplies must be paid for at the time they are

received.

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