trumotion.org - Personal Injury Digital Form

Personal Injury Questionnaire
Confidential Patient Information
Name

First NameLast Name
Date

MonthDayYear
Date
SSN
DOB

MonthDayYear
Date
Gender
Marital Status
Spouse's Name
# of Children
Address
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Contact Method

CellEmail
Occupation
Employer
Emergency Contact
Emergency Relation
Emergency Phone
Please enter a valid phone number.
Injury/Accident Details
Date of Accident

MonthDayYear
Date
Time of Accident

Hour Minutes

AM/PM Option
City
State
Please explain in detail how your accident happened
You were heading

NorthSouthEastWest
On

StreetHighway
Other vehicle was heading

NorthSouthEastWest
On

StreetHighway
Police were notified?

YesNo
Where did you feel pain immediately after the accident?
List the extent of your injuries as you know them
Did you require post accident hospitalization?

YesNo
Were you knocked unconscious?

YesNo
If yes, for how long?
You were struck from

BehindFrontDriver SidePassenger Side
Location in the vehicle

DriverPassengerFront SeatBack Seat
Using seat belts?

YesNo
Check symptoms you have noticed since the accident

HeadacheDizzinessDepressionFatigueLight Sensitive EyesBuzzing in EarsDiarrheaNeck PainHead feels heavyMemory LossFeet ColdNeck StiffPins and Needles in ArmsEars RingingHands ColdFaintingSleeping ProblemsBack PainFace FlushedLoss of BalancePins and Needles in LegsConstipationTensionNervousnessNumbness in FingersLoss of SmellFeverIrritabilityNumbness in ToesLoss of TasteChest PainCold SweatsShortness of BreathStomach UpsetOther
Injury/Accident Details (continued)
What hospital were you taken to (if applicable)?
Admitted

YesNo
If yes, how long?
Name of doctor
What was the diagnosis?
What was the treatment?
How long were you treated?
Was any other doctor consulted after your accident?

YesNo
If yes, what was the doctor's name?
What was the diagnosis?
What was the treatment?
How long were you treated?
Have you ever had complaints in the involved area before?

YesNo
If yes, please explain
Before the injury were you capable of working on an equal basis with others your age?

YesNo
Are your work activities restricted as a result of this accident?

YesNo
Since this injury, are your symptoms:

ImprovingGetting WorseSame
Lifestyle (Not related to the accident)
Are you physically active?

Not at allSomewhatFor the most partYesVery
Physical activities
Quality of sleep

PoorFairAverageGoodExcellent
Do you have any emotional or behavioral issues?

YesNo
Your opinion on chiropractic care?

SkepticalCuriousPassionateIndifferentNervousExcited
Symptoms (Not related to the accident)
Select ALL that apply:

Neck PainChronic SinusitisMid Back PainLow Back PainHeadachesArm NumbnessShoulder PainHip PainMigrainesHand NumbnessHeart DiseaseLeg PainVertigoArm PainAsthmaLeg NumbnessDizzinessThroat IssuesGastric RefluxNumbness in FeetNauseaThyroid ProblemsUlcersKnee PainTMJChronic FatigueChest PainKidney ProblemsEar InfectionsFibromyalgiaChronic IllnessIBSAnxietyLupusLiver DiseaseBladder Problems

	Top 3 Health Concerns	Severity(1=MILD / 10 = UNBEARABLE)	Date of Onset	Did the problem begin with an injury?	Are symptoms constant or intermittent?
1.
2.
3.

Pain Scale (Not related to the accident)

On a scale of 1 to 10, 10 being worst possible pain...
What is your pain level right now?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
What is your average level of pain?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
What is your pain level at its worst?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Health History
List current medications
List all surgical operations and dates
Have you ever been in an auto accident?

YesNo
If yes, please list dates and injuries
Have you even had/have

StrokeCancerHeart DiseaseSpinal SurgerySeizuresSpinal Bone FractureScoliosisDiabetesBone FractureSevere FallConcussion
Have you ever been under regular chiropractic care?

YesNo
If yes, where?
Date of last adjustment

MonthDayYear
Date
Why are you seeking chiropractic care?

Spinal CorrectionPain ReliefPain ManagementMaintain HealthSports PerformanceSymptom ReliefQuality of Life Improvement
What is your main goal in seeking care at our office?
Family History

Select ALL that apply

	Spouse	Daughter	Son	Mother	Father	Grandmother	Grandfather
Arthritis
ADHD/ADD
Bed Wetting
Cancer
Carpal Tunnel
Deceased
Diabetes
Digestive Problems
Ear Infections
Fibromyalgia
High Blood Pressure
Migraines
Scoliosis

Patient Signature

Clear
Date

MonthDayYear
Date
Insurance
Primary Insurance Carrier
Name of Insured
Insured DOB

MonthDayYear
Date
Member ID
Group ID
Secondary Insurance Carrier
Name of Insured
Insured DOB

MonthDayYear
Date
Member ID
Group ID
Release of Authorization/Assignment of Benefits
I authorize and request payment of insurance benefits and agree that this authorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of this form may be used in place of the original. All professional services rendered are charged to the patient. It is customary to pay for services when rendered unless other arrangements have been made in advance. I understand that I am financially responsible for charges not covered by insurance.
Patient Signature

Clear
Date

MonthDayYear
Date
Disclaimer for PI, Auto, or Workmans Compensation
Dear Patient,
This information is considered confidential. We need this information because we care enough to want to know and your answers will help us determine if chiropractic can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. In order for us to understand your condition properly, please be as neat and accurate as possible while completing this form. Thank You.
Patient Name
DOB

MonthDayYear
Date
Patient Signature

Clear
Date

MonthDayYear
Date
Terms of Acceptance
To promote the most effective application of chiropractic procedures and the strongest possible doctor-patient relationship, we state the following to facilitate the goal of optimum health through chiropractic.
To that end, we ask that you acknowledge the following points regarding services we provide:
1. Chiropractic is a specific, separate, and distinct practice authorized by law to address spinal health.
2. Chiropractic seeks to restore normal nerve functioning through the adjustment of spinal subluxations to maximize the inherent healing power of the body. Subluxations are deviations from normal spinal structures that interfere with normal nerve processes.
3. The chiropractic adjustment process, as defined in the law of this jurisdiction, involves the application of a specific directional thrust to a region(s) of the spine with the specific intent of repositioning misaligned spinal segments. This is a safe, effective procedure applied over one
  million times each day by doctors of chiropractic in the united states alone.
4. Chiropractic does not seek to replace or compete with other specific health care professionals. They retain responsibility for care and management of medical conditions. We do not offer advice regarding treatment prescribed by others.
5. Your compliance with the doctor’s recommendations is essential to achieving the maximum health benefits.
6. We invite you to speak frankly to the doctor on any matter related to your care at this facility, its nature, duration, or cost, what we work to maintain as a supporting, open environment.
By signing below, i am stating that i have fully read and understand the above statements.
Patient Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Personal Injury Questionnaire

Confidential Patient Information

Injury/Accident Details

Injury/Accident Details (continued)

Lifestyle (Not related to the accident)

Symptoms (Not related to the accident)

Pain Scale (Not related to the accident)

Health History

Family History

Insurance

Release of Authorization/Assignment of Benefits

Disclaimer for PI, Auto, or Workmans Compensation

Terms of Acceptance