Motor Vehicle Accident Intake Forms

Motor Vehicle Accident Intake Forms

Rehabilitation Chiropractic dba Aaaah...Wellness
Health Questionnaire
Your Name*

First NameMiddle NameLast Name
Your Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date

How would you rate your energy level?*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

What is your energy level at the highest?*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

What is your energy level at the lowest?*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

How many hours on average per night do you sleep?*

2-44-66-88+
Do you have trouble falling asleep?*

YesNo

How would you rate your stress level?*

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

How would you rate your daily activity?*

SedentaryLightly ActiveActiveVery Active
What would you like your daily activity level to be?*

SedentaryLightly ActiveActiveVery Active
How would you rate your diet on average?*

Very PoorPoorAverageAbove AverageHealthy
What level would you like your diet to be at?*

Very PoorPoorAverageAbove AverageHealthy
Which of the following would you like to improve? (You may check more than one)*

Quality of LifeDisease PreventionLongevityBody RecompositionPerformance
Symptoms

Please fill in all symptoms you currently have that you DID NOT have before that accident
Orthopedic & Musculoskeletal Symptoms

"Clunk" sound with neck movementsNeck painUpper back painLow back painShoulder painUpper arm painElbow PainForearm painWrist painHand painHip painUpper leg painAnkle painFoot painJaw painClicking in JawPain when chewingFace PainChest painStomach painBruiseScrape/ cutOther
If selected "Shoulder pain", which side?

LeftRight
If selected "Upper arm pain", which side?

LeftRight
If selected "Elbow Pain", which side?

LeftRight
If selected "Forearm pain", which side?

LeftRight
If selected "Wrist pain", which side?

LeftRight
If selected "Hand pain", which side?

LeftRight
If selected "Hip pain", which side?

LeftRight
If selected "Upper leg pain", which side?

LeftRight
If selected "Ankle pain", which side?

LeftRight
If selected "Foot pain", which side?

LeftRight
If selected "Face Pain", please explain which area(s)
If selected "Bruise", please explain which area(s)
If selected "Scrape/Cut", please explain which area(s)
Neurological Symptoms
Numb/Tingling Arm/Hand

LeftRight
Numb/Tingling Leg/Foot

LeftRight
Weakness Arm/Hand

LeftRight
Weakness Leg/Foot

LeftRight
Symptoms Associated with Injuries

Stiffness or limited movement in joint(s)HeadachesMuscle spasms/sore musclesDizziness, lightness, woozy feelingVisual distrubances or vision changeSleep changes/distruption of patternsPain radiates from one place to anotherAnxiety or nervous when drivingIrregular heartbeat or uneven pulseFeeling depressed about things
List all medications taking, if any
Brain/Neuropsych/MTBI/PTSD Symptoms

I prefer being alone now (not socializing)I am sleepy, tired during the day or doze off easilyUpset stomach, nausea, heartburn or vomitingDifficulty concentrating, mind wanders easilyI get overwhelmed easilyMood swings, happy one moment then sadAgitation (can't sit still, need to move around)Sadness, tearful episodes, crying easilyBlurry vision, had to get or change glassesAsking people to repaet things or hearing problemsI make wrong turns driving or can't remember timeI get confused easily or cannot multi-task anymoreI have difficulty finding some words when talkingBright lights bother meI cannot pay attention as long as beforeRoom spins, lightheaded or woozy feelingBalance problemsI feel like my head is "foggy"I have forgetten computer passwords or ATM PINI have to re-read things to understand what I readMy thinking is slowed downDifficulty with adding/subtracting numbersFear I will never be the same againDifficulty learning new thingsDifficulty understanding what people say to meDifficulty remembering or memory problemsCannot take on anymore responsibilityI can't make decisions as quickly as beforeLoss of libido or lack of sexual desireI do not feel as confident of my abilitiesI get panic attacks, fast heartbeat, nervousI am more irritable than usualSome food or drink tastes "funny" to me nowI get frustrated very easilyDifficulty planning my life or organizing my workFlashbacks or frightening thoughts about accidentI have had bad dreams about the accidentI avoid places & objects that remind me about itI feel emotionally numb- no interest in my hobbiesI'm feeling strong guilt, worry or depressionI am having trouble remember the accidentI am easily startled since the accident- "jumpy"I feel tense or "on edge" most of the timeI am having difficulty sleepingI get angry easily or even yell at people now
Signature*

Clear
Consent To Treat
Dear New or Returning Patient:

Welcome to the health care facility of Rehabilitation Chiropractic Care P.C. this facility is primarily interested in teaching the benefits of receiving preventative chiropractic care, proper nutrition and rehabilitative exercise to our patients. Our licensed professional staff will treat you with modern treatment modes.

Terms of Agreement:

Please check the box to confirm that you understand and acknowledge the following criteria:
Consent for Chiropractic Treatment – I hereby consent to the performance of spinal manipulations, acupuncture and any other chiropractic procedures, including but not limited to examination tests, diagnostic x-rays, physiotherapy techniques, nutritional advice and rehabilitative exercise on me. Minor consent – I hereby give Rehabilitation Chiropractic Care P.C. or staffs consent to treat myself/my minor child. I am welcome to observe the treatments.*

I understand
Risk – I understand that as with any health care procedures, there are certain complications which may arise during a chiropractic adjustment. Those complications include but are not limited to: fracture, disc injuries, dislocations, muscle strain, Horner’s Syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. I understand that the chiropractor can not be expected to anticipate all risks and complications associated with manipulations but will rely on their expertise of judgment and training during the course of the procedure(s) which the doctor feels at the time, based upon the facts then known, are in my best interest.*

I understand
Results – I understand that results are not guaranteed. I have read ( ) or have had read to me ( ) the above explanation of the chiropractic adjustment and related treatment. By signing below I state that I have weighed the risks involved in undergoing treatment and have hereby consented to the treatments recommended by the doctor. I intend for this consent to cover the entire course of my treatment for my present condition(s) and for any future condition(s) for which I seek treatment.*

I understand
Nutritional Advice – I understand that I am not receiving a medical diagnosis or treatment procedure of my illness or disease. Any supplements, herbs, or homeopathic remedies that may be suggested are not to be misconstrued as prescription or curative of any disease process. All consultations are of a nutritional nature and intended to maintain a state of good health and do not involve diagnosing or prescribing remedies for the treatment of disease.*

I understand
Accurate Information – I acknowledge that all information is factual and complete. After reading and filling out my patient intake forms, I state that all of the information given is accurate and reflects my current health status. To facilitate safe, effective chiropractic care, I understand that my records must be up-to-date. I am responsible in notifying the doctor and staff of any changes to my healthcare to include but not limited to: illness, surgeries, accidents, or other injuries.*

I understand
Treatment Plan and Assessment – After detailed evaluation of your current symptomatolgy and special health concerns, the doctor will go over this plan with you totally and stress the importance of the patient’s diligent follow-through. This plan has been customized for your specific health concerns and treatments of such and we ask for your participation and active commitment for optimal results. Failure to complete the recommended plan may result in set backs in your care. I understand the doctor and staff are committed to my treatment and I will make appointments in conjunction with this plan.*

I understand
Termination – I understand that the doctor(s) have the right to select their cases and patients. The patient has the right to continuity of care once the doctor has agreed to treat the patient. The chiropractor may terminate the patient-doctor relationship only when the patient has been given reasonable notice. It is permissible for the doctor to terminate the patient-doctor relationship when the patient fails to cooperate.*

I understand
X-Rays (who owns them?) – According to the Chiropractic Board, custody of patient records is as follows: Interspective material, including x-rays taken during the course of chiropractic treatment, is the work-by-product of the physican and is the doctor’s property. X-ray reports will be provided to other physicians with a medical release form from the patient upon request.*

I understand
Payment Terms – I understand that payments (including insurance deductibles, co-insurance and co-payments) are due at time of service, unless otherwise agreed to in writing. The patient is responsible for their medical bills. I further understand that interest and/or late payment fees will be charged to delinquent accounts. Payment is due upon receipt on invoice. Payment arrangements are available upon advanced request. *

I understand
Appointment Policies and Fees – I understand that I am expected to be on time for my appointment and if I am late I will be asked to wait or reschedule for a later time the day if possible. I understand that I must notify the office 24 hours in advanced in order to cancel my appointment and if I fail to do so, my account will be charged a late fee which is posted in the office.*

I understand
Release of Records – A Chiropractic physician shall make available within a reasonable time to a patient or a third party upon the patient's written request, copies or summaries of medical records and originals or copies of the patient's x-rays. The Chiropractic physician shall preserve a patient's medical records from disclosure and will release them only on a patient's written consent stating to whom the records are being released or as required by State or Federal law. I authorize Rehabilitation Chiropractic Care, P.C. to release any information deemed appropriate concerning my physical condition to any insurance company, attorney or adjuster in order to process any claim for re-imbursement of charges incurred by me as a result if professional services rendered at by this clinic and I herby release you of any consequences.*

I understand
Arbitration – I understand and acknowledge the following: any claims, controversy or dispute as to medical malpractice between doctor (staff) and patient, whether any medical services rendered under this contract were unnecessary or unauthorized, or were inappropriate, negligently or incompletely rendered which is not resolved through good faith negotiations shall be resolved by arbitration in accordance with the Federal Arbitration Act 12-1501. Both parties to contract by entering into it are giving up their constitutional right to have such dispute decided in a court of law before a jury and instead are accepting the use of arbitration. A neutral arbitrator, who is a resident of the state in which the clinic operates, shall conduct the arbitration under the current rule of the Arizona Arbitration Association and all expedited procedures prescribed by the AAA ruler shall apply. The Arbitrator shall have authority to award compensatory damages only. Any claims, controversy or dispute as to medical malpractice between doctor (staff) and patient. The arbitrators’ award shall be final and binding and may be entered in any court having jurisdiction thereof. Each party to the arbitration shall pay such party’s, pro-rata share of the expenses and fees of the neutral arbitrator together with other expenses of the arbitration incurred or approved by the neutral arbitrations not included counsel fees, or other expenses incurred by a party for such party’s own benefit.*

I understand
Any controversy or claim arising out of or relating to this contract, or the breach thereof, shall be settled by arbitration administered by the American Arbitration Association in accordance with its Commercial Arbitration Rules, and judgment on the reward rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof.

If a dispute arises out of or relates to the contract, or is breached and the dispute cannot be settled through negotiation, the parties agree first to try in good faith to settle the dispute by mediation administered by the American Arbitration Association under its Commercial Meditation Rules, before resorting to arbitration, litigation, or some other dispute resolution procedure.
Occupation
Company/Employer
Name*

First NameLast Name
How did you hear about us?*
Signature*

Clear
Today's Date*

MonthDayYear
Date
HIPAA Privacy Compliance Policy

Effective 6/01/09
We Will Keep Your Medical Information Confidential

THIS NOTICE IS PRESENTED IN COMPLIANCE WITH FEDERAL HIPAA REQUIREMENTS FOR HEALTH CARE PROVIDERS AND DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

HIPAA “The privacy provisions of the federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), apply to health information created or maintained by health care providers who engage in certain electronic transactions, health plans, and health care clearinghouses. The Department of Health and Human Services (HHS) has issued the regulation, "Standards for Privacy of Individually Identifiable Health Information," applicable to entities covered by HIPAA. The Office for Civil Rights (OCR) is the Departmental component responsible for implementing and enforcing the privacy regulation. (See the Statement of Delegation of Authority to the Office for Civil Rights, as published in the Federal Register on December 28, 2000.”

Question: What is this HIPAA compliance form all about?
Answer: HIPAA requires all Health Care Practitioners to keep your health-related information private, releasing us to release pertinent information to:
1. Your insurance company or other 3rd party payer, so they can pay your bill.
2. Your other doctors, for information you want them to have from us.
3. Your attorney or anyone else you request and authorize us to release it to.
4. Our business partners. Examples: Outside billing companies, outside marketing companies that might produce and mail our newsletters, etc. If we use any such company, they too will maintain the same level of privacy we maintain.
5. Your legal representative(s), should you for any reason become unable to speak and or act for yourself in making health care related decisions.
6. Your providers of emergency treatment as consistent with our awareness of your needs and the doctor’s best judgment.Example: You are in the emergency room and they need medical information about you from us.
7. Your family, friends or others that may answer your phone, read your mail, or otherwise communicate with us as part of our exchanging information with one another that is necessary to your care and relationship with this office. Examples: We can call your home and leave a message for you on your answering machine or with any person that answers. We can send you a fax or e-mail that might be read by any other person with access to your fax or e-mail. We can leave a message for you at work on any recording device or with any person limited to our name, phone number, and the level of necessity /urgency that you contact us.
8. You should be aware that government agencies can abridge your right to privacy and legally require us to release information even against your will. Examples: In cases of child abuse where the parent does not authorize the release of this information. In instances where you might be a threat to yourself or others (i.e., suicidal). The office will obey the law in respect to any current or future requirements to report or release information.
9. The treatment rooms are not enclosed, and the patient is aware that unless otherwise requested, information relevant to their visits will be discussed in the treatment rooms. The patient can request that they speak with the Doctor regarding test results, information specific to their care and other relevant information be discussed in an enclosed room if one is available.
YOU CAN REVIEW, RESTRICT AND/OR REVOKE ACCESS TO YOUR INFORMATION

Space is provided on subsequent pages of this form for you to list any objections, restrictions, limitations etc. that you want to apply to your information in our office. This can include the names of individuals that are to have no or limited access to your information and if limited the parameters of that limitation. Example: The name of your 14-year-old child where you allow that we can leave messages for you but not discuss the details of your health. You can update this information at any time, in person or over the phone. Example: You still live with a significant other, but you no longer want us to leave any messages with them.

By signing below, I acknowledge that I understand and agree to the above and can request a copy of this notice. I have indicated any restrictions I wish to apply to my records on the reverse side of this page.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Name of Parent or Guardian

First NameLast Name
Signature of Parent or Guardian

Clear
Date

MonthDayYear
Date
Medical Information Release Form

HIPAA Release Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Release of Information*

I authorize the release of information including the diagnosis, records; examination rendered tome and claims information.Information is not to be released to anyone.
If you clicked to authorize release of information above, please enter the name(s) of the people with authorization in the text box below.
Example: Spouse - First Last, Children - First Last, Mother - First Last
*This Release of Information will remain in effect until terminated by me in writing.
Messages Please call me at:*

HomeWorkCell
Home Phone Number*

Area CodePhone Number
Work Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
If unable to reach me:*

you may leave a detailed messageplease leave a message asking me to return your calltext me at the following phone numberOther
The best time to reach me is (day)
Sun, Mon, Tues, Wed, Thu, Fri, Sat
between (time)
Example: 8AM - 12PM
Coordination of Care

Please list the name and phone number of your Primary Care Physician:
Physician Name
Physician Phone Number

Area CodePhone Number
It is our intention to communicate with your primary care physician to coordinate the care being provided in this office. This is an effort to maintain the highest quality of care for you and your family. Should you not want us to communicate with them please indicate by checking the appropriate box below.

You are welcome to communicate with my PCP.I would prefer you not communicate with my PCP.
I have read and fully understand the above statements.*

Confirmed
Signature*

Clear
Date*

MonthDayYear
Date
Consent To Treat A Minor

Arizona law requires consent from a parent/legal guardian for healthcare of a minor.
Is the patient under the age of 18?

NoYes
I, (print name)

First NameLast Name
the parent/legal guardian of (minors name)

First NameLast Name
do hereby consent to any medical care conducted here at Aaaah… Wellness, by its doctors and/or staff to provide healthcare to my son/daughter, including, but not limited to, diagnostic examinations, radiological testing, laboratory testing, and all treatment deemed necessary.

I further understand that once my child reaches the age of 18, my consent for treatment is no longer required.
Signature of Parent/Legal Guardian

Clear
Date

MonthDayYear
Date
Should be Empty:

Motor Vehicle Accident Intake Forms

Health Questionnaire

Symptoms

Consent To Treat

HIPAA Privacy Compliance Policy

Medical Information Release Form

Coordination of Care

Consent To Treat A Minor