New Patient Paperwork
Motor Vehicle Accident in the past three months
CONFIDENTIAL PATIENT HEALTH HISTORY
Today's Date:
/
Month
/
Day
Year
PATIENT INFORMATION
Name: (Last, First, MI)
Preferred Name:
Date of Birth
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Year
Address
Address
Street Address Line 2
City
State
Zip
Home Phone:
Mobile:
Work:
Social Security number:
Height:
Weight:
Email:
example@example.com
Gender:
Marital Status:
Married
Single
Other
Occupation:
Employer:
Spouse/Significant Other:
Childrens Names and Ages:
Are you:
Military Veteran
Active Duty Service Member
Reservist
National Guard
ROTC
Referred by:
Family
Friend
CoWorker
Doctor
Other
Referred by (name):
Preferred Language:
Ethnicity
NOT Hispanic or Latino
Hispanic or Latino
Other
Decline to Answer
Race:
Asian
Black or African American
American Indian or Alaskan Native
White (caucasian)
Hawaiian or Pacific Islander
Other
Decline
CMS requires providers to report both race and ethnicity
Smoking Status
Every Day
Some Days
Former
Never
Are you pregnant?
Yes
No
If yes, how many weeks and who is on your birth team?
EMERGENCY CONTACT INFORMATION
Full Name:
Preferred Contact Number:
Relationship:
Child
Parent
Spouse
Other
Primary Care Physician:
Primary Care Physician's Phone Number:
Financial Status
Self Pay (Cash)
Insurance
Personal Injury/Auto
If possible, please attach a picture of the FRONT of your insurance card
Browse Files
Cancel
of
If possible, please attach a picture of the BACK of your insurance card
Browse Files
Cancel
of
Primary Insurance:
Secondary Insurance:
Name of Policy Holder:
Relation to Insured
Self
Spouse
Parent
Child
Back
Next
Auto Accident Questionnaire
Date of Accident
-
Month
-
Day
Year
Date
Number of People in the Accident
Name of the Driver of the vehicle you were in
Were you the:
Driver
Front Passenger
Rear Passenger
Were you wearing a seatbelt?:
Yes
No
Did the airbags inflate?
Yes
No
Where was your vehicle impacted?
Front
Rear
Driver Side
Passenger Side
Did any part of your body strike anything in the vehicle? If yes, please describe:
Did you lose consciousness? If yes, for how long?
Were you aware or surprised by the impact?
Aware
Surprised
Medical Information BEFORE the Accident
Have you ever had complaints in the involved area? If yes, were they present at the time of the accident?
Were you able to work without restrictions before the accident?
Yes
No
At the time of the accident:
When did you start to feel pain?
Immediately after the accident
Later that day
The next day
No pain
Did you go to a hospital or see a doctor after the accident?
Yes
No
If yes, when did you go?
Same day as the accident
Next Day
If you did seek medical attention, how did you get there?
Ambluance
Private Transportation
Please list the name of any medical facilities you went to:
Were X-Rays taken?
Yes
No
Was any medication prescribed to you?
Yes
No
Since the Accident:
Are your symptoms:
Getting Better
Staying the Same
Getting Worse
Are your work activities restricted because of this injury? If yes, please describe how:
Have you missed work since this accident?
Yes
No
Legal Information
Please bring the following to your FIRST visit:
Name of your Car Insurance Company and or Medpay provider
Your Insurance Policy Number
Your Insurance Claim Number
Name of your Adjuster
How much is your Medpay?
If you have retained an attorney please list the name AND phone number
Name of the OTHER DRIVERS Car Insurance Company
The OTHER DRIVERS Policy Number
The OTHER DRIVERS Claim Number
The OTHER DRIVERS Adjusters name and phone number
Back
Next
Current Condition Information
Please Answer ALL Questions
Major Complaint:
When Did It Start (date):
What Event Caused It:
Is the Complaint:
Constant
On and Off
Is the Complaint
Sharp
Burning
Dull
Pins and Needles
Stabbing
Achy
Stiff and Sore
Other
Intensity
None
Mild
Moderate
Severe
Does it Radiate/Shoot to any areas of your body?
No
Yes
If YES, where:
Draw Areas of Complaints
What makes it better?
Ice
Heat
Rest
Movement
Stretching
Over the counter medication
Prescription medication
Chiropractic
What makes it worse?
Sit
Stand
Walk
Lying
Sleep
Movement
Who else have you seen for this?
No One
Doctor of Chiropractic
Medical Doctor
Physical Therapist
Masseuse
Emergency Room
Where did you receive this service?:
Diagnostic Tests you have had done for this complaint:
None
X-Rays
MRI
CT Scan
When and Where these tests were completed:
Any Other Complaints?:
Please list your top three health goals?
1.
2.
3.
Back
Next
Past History
Does anyone in your IMMEDIATE family have a history of:
Heart Disease: If yes, who
Stroke: If yes, who
Cancer: If yes, who
Other Relevant Family History:
Past Health History (List any Injuries, Traumas, or Hospitalizations in the last 20 years):
List any:Car Accidents, Falls, Sports Injuries
List any Surgeries: Date, Type, and Reason
List any medications, vitamins and supplements you are taking: (If you prefer you can bring a list and we will make a copy)
List any Allergies to Medications:
Are you CURRENTLY experiencing any of these symptoms?
Check all that apply
General:
Recent Intentional Weight Change
Fever
Fatigue
None in this category
Musculoskeletal:
Low Back Pain
Mid Back Pain
Neck Pain
Arm Problems
Leg Problems
Broken Bones
Muscle Spasms/Cramps
None
Neurological
Numbness or Tingling Sensations
Loss of Feeling
Dizziness or Light Headed
Frequent or Recurrent Headaches
Convulsions or Seizures
None
Have you ever had a head injury? If so, what year?
Gastrointestinal
Loss of Appetite
Blood in Stool
Change in Bowel Movements
Nausea or Vomiting
Abdominal Pain
Constipation
None
Cardiovascular & Heart
Chest Pains
Rapid or Heartbeat CHanges
Blood Pressure Problems
Swelling of Hands, Ankles, or Feet
Heart Problems
None
Respiratory
Difficulty Breathing
Persistent Cough
Coughing Blood
Asthma or Wheezing
Tobacco Use
None
Eyes & Vision
Wears Contacts/ Glasses
Blurred or Double Vision
Eye Disease or Injury
None
Ears, Nose & Throat
Swollen Glands in Neck
Ringing in Ears
Ear Ache/Ringing/ Drainage
Sinus/ Allergy Problems
None
Mind/Stress
Nervousness
Depression
Sleep Problems
Memory Loss or Confusion
None
Endocrine, Hematologic & Lymphatic
Thyroid Problems
Diabetes
Cold Extremities
Heat or Cold Intolerance
Immune System Disorder
None
Skin & Breasts
Rash or Itching
Non- Healing Sores
Breast Pain
Breast Discharge
None
Genitourinary
Kidney Stones
Burning/ Painful Urination
Change in Force/Strain with Urination
Urinary Leakage or Bed Wettng
Blood in Urine
None
Pregnancies with Outcome & Date
/
Month
/
Day
Year
Date
Women: Are you pregnant? If yes, write in due date
Women: If you are NOT pregnant, write down date of last menstrual period
Women: Previous Pregnancies Outcome and Date
Women: Check any that apply
Painful or Irregular Periods
Urine Leakage with Coughing or Sneezing
Urine Leakage with Laughing or Lifting
None
Is there anything else you would like us to know?
Please sign below to indicate that you have read the above information and have filled out this form as accurately as possible.
Signature
Clear
I have reviewed the HIPAA privacy practices for Frederick Chiropractic (above).
Parent or Guardian Signature
Clear
Date
-
Month
-
Day
Year
Please verify that you are human
*
All Set! Select "Submit" below, and we will receive your information. We look forward to meeting you.
-Frederick Chiropractic Team
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