FORMS

Please fill out the form below or Download and Print this form

    Lets Get Started

    Step 1 of 5 ( 20% )

    1

    Your Information

    2

    Employment Information

    3

    Health Information

    4

    Symptoms

    5

    Pain Measurement

    New Patient Information (*=Required Field)


















    MaleFemale

    SingleMarriedSeparatedDivorcedWidowed
















    SpouseFamilyFriendOther








    SpouseFamilyFriendOther


    Insurance Information


    YesNo


    If yes please bring insurance card to the office on your first visit.

    Auto Insurance Information


    Auto InsurancePersonal Injury Protection (PPP)Uninsured MotoristMed Pay















    Third Party Liability (if applicable)










     If you do not have the information of the person at fault, please bring the third party liability information with you on your next visit. Thank you! 



    Pre-Injury Health History Questionnaire

    Step 2 of 5 ( 40% )

    1

    Step1

    2

    Step2

    3

    Step3

    4

    Step4

    5

    Step5

    Review of Symptoms


    FaintingLow LibidoPoor AppetiteFatigueSudden Weight GainSudden Weight LossWeaknessNone of the Above

    AsthmaApneaEmphysemaHay FeverShortness of BreathPneumoniaNone of the Above

    High Blood PressureLow Blood PressureHigh CholesterolPoor CirculationAnginaExcessive BleedingNone of the Above

    Anorexia/BulimiaUlcerFood SensitivitiesHeartburnConstipationDiarrheaNone of the Above

    Kidney StonesInfertilityBedwettingProstate IssuesErectile DysfunctionPMS SymptomsNone of the Above

    Skin CancerPsoriasisEczemaAcneHair LossRashNone of the Above

    Blurred VisionRinging in EarsHearing LossChronic Ear InfectionLoss of SmellLoss of TasteNone of the Above


    Thyroid IssuesImmune DisordersHypoglycemiaFrequent InfectionSwollen GlandsLow EnergyNone of the Above

    History

    Mother's Family History




    GoodFairPoor

    NaturalIllnessOtherN/A-Still Living

    CancerStrokeHeart DiseaseDiabetesAuto-ImmuneN/A


    Father's Family History





    GoodFairPoor


    NaturalIllnessOtherN/A-Still Living

    CancerStrokeHeart DiseaseDiabetesAuto-ImmuneN/A


    Social History
















    Past Medical History


    AIDSAlcoholismAllergiesArteriosclerosisCancerChicken PoxDiabetesEpilepsyGlaucomaGoiterGoutHeart diseaseHepatitisHIV PositiveMalariaMeaslesMultiple SclerosisMumpsScarlet feverSexually transmitted diseasePolioRheumatic feverStrokeTuberculosisTyphoid feverUlcerNone





    Any surgeries PRIOR to injury?


    NoneAppendix removalBypass surgeryCancer relatedCosmetic surgeryEye surgeryHysterectomyPacemakerTonsillectomySpinal SurgeryJoint Surgery






    Medications & Allergies


    Please list below all prescription, over-the-counter or natural supplements you are taking




    Are you allergic to any medications?


    YesNo

    If yes, please list


    Dominant Hand



    RightLeftAmbidextrous (both)


    You Are @ Step 3 Now!

    Step 3 of 5 ( 60% )

    1

    Step1

    2

    Step2

    3

    Step3

    4

    Step4

    5

    Step5



    ACCIDENT INFORMATION



    Select The Type of Accident You Had


    Slip & FallAuto Accident



    "PERSONAL INJURY or SLIP/FALL"


    YesNo


    Describe How and Where the injury occurred:











    FallSlipTripOther

    ForwardBackwardsLeftRight





    YesNo





    YesNo




    YesNo

    YesNo


    Upload INJURY Pictures


    "MOTOR VEHICLE ACCIDENT (Patient)"


    Yes (Bring Copy)No









    YesNoUnsure

    YesNoUnsure

    YesNoUnsure

    YesNoUnsure

    Traffic-Light4-Way Stop2-Way StopParking LotHighwayOther






    Motor Vehicle Information






    Rear-endedFront-end impactedT-Boned Driver-PassengerRolloverSide Impact Driver-PassengerOther



    FrontSideRear



    DryRainIceFog

    MorningNoonAfternoonEvening






    MECHANISM OF INJURY





    DriverFront PassengerLeft-Rear PassengerMiddle-Rear PassengerRight-Rear PassengerOther


    YesNo

    YesNo

    YesNo

    Straight AheadLeftRightUnsure

    YesNoUnsure



    Upload MOTOR VEHICLE ACCIDENT Pictures


    Upload INJURY Pictures

    You Are @ Step 4 Now!

    Step 4 of 5 ( 80% )

    1

    Step1

    2

    Step2

    3

    Step3

    4

    Step4

    5

    Step5


    Post-Injury Questionnaire


    YesNo

    YesNo



    Immediately AfterA few hours afterOne day laterA few days laterCan't Remember

    MRICT ScanX-RaysTests conducted Lying DownTests Conducted Standing



    YesNo

    YesNo





    SINCE THE ACCIDENT


    Prescription medicationOTC medicationHomeopathic remediesSurgeryAcupunctureChiropractic careIceHeatMassagePhysical TherapyRestPain Relief CreamsWearing a support/braceOther





    ACTIVITIES OF DAILY LIVING


    SittingRising out of chairStandingWalkingLying downBending overClimbing stairsDriving a carTurning headHousehold choresLifting objectsReaching upShowering or bathingGetting dressedLove lifeSleepConcentratingExercisingOther





    Work Status


    YesNo




    YesNo




    YesNo

    StudentRetiredDisabledHomemaker


    A doctor took you off workYou took yourself off workYou had no transportation after the accidentYour boss took you off workYou were fired or lost your job as a result of this accidentOther




    YesNo

    YesNo


    YesNo





    GAP





    I’ve been taking medication as prescribed. My pain still persists.I don’t usually run to the doctor when I first experience pain; however, I’m not better.I tried to treat myself at home; however, the pain did not go away.I was feeling okay at the scene of the accident, but the pain worsened in the days following.I wanted to wait to see if the pain would go away. I am still in pain.I was treated at a different clinic for a time, but I am not feeling better. I am here for a second opinion.Other




    YesNo


    YesNo


    You Are @ Step 5 Now!

    Step 5 of 5 ( 100% )

    1

    Step1

    2

    Step2

    3

    Step3

    4

    Step4

    5

    Step5

    Functional Rating Index

    In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities. For each item below, please select each item which most closely describes your condition right now.

    Rate Your Pain Intensity

    Rate Your Sleeping

    Personal Care (washing, dressing, etc.)

    Travel (driving, etc.)

    Working

    Recreation

    Frequency of Pain

    Lifting

    Walking

    Standing

    Any information that is not provided while filling out this form will need to be reviewed at the clinic on your first visit. By providing this information at this time, your initial appointment intake process will not be so lengthy. Your doctor will need a health history to complete the initial exam.

    Additional forms will need to be signed when you arrive at the clinic on your first visit. Please bring a photo ID and any previous care information related to your accident if applicable. Thank you!