Avisechiropractic.com - Auto Accident

Confidential Health Questionnaire
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Health History
List any surgeries (include reason & date)
List any hospitalizations (include reason & date)
List any current and past major medical conditions you have had (cancer, diabetes, heart disease, arthritis, etc.)
List any health conditions that run in your family:
Have you ever been in an Auto Accident?

YesNo
When?
How many?
When was your last Physical?
With Dr.
Have you ever been under Chiropractic care?

YesNo
With Dr.
Do you exercise?

NeverOccasionallyFrequently
Do you Smoke/ use Tobacco?

YesNo
Do you have any allergies (food, medication, seasonal, etc.)

YesNo
List:
If female, Is there any possibility that you are pregnant?

YesNo
Date of last menstrual cycle?

MonthDayYear
Date
REVIEW OF SYSTEMS:

Please mark either PAST or NEW for anything you have experienced.

	Past	Now	Doctor's Comments:
General Health (e.g. Fatigue, Stressed)
Mind (e.g. Depression, Anxiety)
Neurologic (e.g. Stroke, Seizure, H.A.)
Visual (e.g. Blurred Vision, Double)
ENT/Mouth (e.g. Ringing in Ears, Jaw Pain)
Hearth (e.g. Heart attack, Pacemaker)
Breathing (e.g. Asthma, Short of breath)
GI (e.g. Vomiting, Diarrhea, Ulcer)
GU (e.g. Incontinence, Sexual Dis.)
Endocrine (e.g. Diabetes, Thyroid Disease)
Sinus Immune (e.g. Congestion, Freq. Cold/Flu)
Musculoskeletal (e.g. Neck, Mid, Low Back pain)

Automobile Accident History
What bleeding cuts and/or bruises did you receive during the accident?
Did any part of your body hit any part of the automobile?

YesNo
If yes, please describe
What is the estimated cost of damage to the vehicle you were in?
Which of the following car parts were damaged in the accident?

WindshieldSteering WheelFront SeatR or L side windowRear view mirrorOther
Was the truck of your body pointing straight forward at the time of collision?

YesNo
If no, in which direction was it turned?
Was your head pointing straight forward at the time of collision?

YesNo
If no, in which direction was it turned?
Since the accident, have you noticed?

Reduced EnergySuicidal thoughtsIndecisiveLoss of interest in activates or hobbiesChange in sex driveDifficulty concentratingAppetite changes (Increased/Decreased)Weight changes (Increased/Decreased)Waking in the middle of the night
Weight changes (Increased/Decreased) # of pounds
What is causing you to wake up in the middle of the night?
Cirlce the number below to indicate your level of pain
Right now/Today

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Extreme Pain
At the time of the Accident

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Extreme Pain
The following questions pertain to the other vehicle invloved in the accident:
Was the other car stopped at the time of the impact?

YesNo
If no, estimate the speed
MPH
If moving, was the vehicle:

Slowing downGaining speedTraveling at a steady rate of speed
DID ANY PART OF YOUR HEAD HIT ANY PART OF THE CAR?

YesNo
WHAT AREA OF HEAD WAS HIT?
Did you lose consciousness or black out for any amount of time after the head injury?

YesNo
How Long?
Had you lost any memory before head injury?

YesNo
Have you lost any memory or has your memory been different since the head injury?

YesNo
Did you have a lump or bruise after the head injury?

YesNo
Where?
Have you had any head injuries in your past? (include childhood)

YesNo
Have you seen other doctors for this head injury?

YesNo
Have you had any x-rays taken?

YesNo
Have you had a CT or MRI scan taken of your head?

YesNo
Please circle the following symptoms that you have had recently since your neck or head injury?

HeadachesBlurry visionLoss of coordinationLoss of balanceReduce drive/motivationDifficulty handling multiple tasksPoor memoryDizziness/lightheadednessDifficulty finishing tasksIrritabilitySleep disorderPersonality changeAbnormal levels of anxietyHand tremorsReduced tolerance of alcoholRinging in earsMore assertiveLess diplomatic than normalForgetfulMood swingsAnger outburstsReduced attention spanDepressionBlack outsFatigueIndifference to other peopleAbsence of ability to anticipateMore shallow relationshipsInflexibilityDifficulty with problem solvingImpaired sexual functionLess mental staminaLanguage difficultyPerformance inconsistenciesImpaired judgementVerbal learning problemsSlow reaction timeNeed day times to remember home/work activities
Personal Injury Questionnaire
PATIENT INFORMATION
Name:

First NameLast Name
Accident date:

MonthDayYear
Date
Accident location:
In which direction you were headed?
Was there a police report filed?

YesNo
If yes, please provide a copy of the police report that was filed.
Make, Year/Model of the vehicle:
Insurance company's name:
Policy number:
Are you the insured driver on the policy?

YesNo
If no, please list the name of insured driver:
Claim number:
Adjusters name:
Adjusters Phone Number:
Please enter a valid phone number.
Do you have an attorney?

YesNo
Attorneys name:
Attorneys address:
Attorneys phone number:
Please enter a valid phone number.
AT FAULT DRIVERS INFORMATION
Name:
Address:
Insurance company's name:
Make/Year/Model of the vehicle:

Assignment of benefits for personal injury or motor vehicle accident.

I hereby assign all medical benefits, to include all major medical benefits to which
I am entitled to Avise Chiropractic.

I understand that I am responsible for all charges, whether or not paid by stated insurance; I hereby authorize said assignee to release any and all information necessary to secure payment. If I have personal injury protection (PIP) or Med Pay through my automobile insurance, Avise Chiropractic will bill my insurance carrier directly, as long as my PIP/MP claim application has been filed. If no application has been filed, Avise Chiropractic will bill me directly, as I am responsible for payment of all services rendered.

If I do not have PIP/MP coverage and the other party is clearly at fault, as stated on the police report, a lien will be filed to secure payment to Avise Chiropractic, PLLC for the treatment of my injuries.
Signature:

Clear
Date:

MonthDayYear
Date

Terms of Acceptance
At our office we offer Chiropractic Care to treat Vertebral Subluxations. We do not offer to diagnose or treat any disease or condition other than subluxations. However, if during the course of an examination we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice for those findings we will recommend you to a provider who specializes in that area.
OUR ONLY PRACTICE OBJECTIVE is to eliminate major interference through a specific chiropractic adjustment to correct the vertebral subluxation. If you need to spend extra time discussing your health with the doctor, please let our staff know so that we may schedule your next appointment accordingly.
I Name have read and understand the above statements. All my questions regarding the doctor's objectives pertaining to my care have been answered to my complete satisfaction. Initial

*In order to diagnose subluxation the doctor may take x-rays. I certify to the best of my knowledge I am not pregnant and the doctor has my permission to perform an x-ray. I have been advised that an x-ray can be hazardous to an unborn child.

I Name certify that there NO chance of pregnancy. Initial
Office Policy

Keeping your appointments is vital to getting you back on track and healthy. We do not charged for missed appointments for chiropractic but ask that you immediately call to reschedule. When arriving for your appointments please go to the front desk and sign in. This will help us to keep you on time and to the appointed doctor or therapist. Initial
Financial Policy

To reduce confusion and misunderstandings between patients and the practice, we have adopted the following financial policies:
All copayments, deductibles and non insurance covered charges must be paid at time of service.     Initial
We will prepare and send all claims to your insurance on your behalf.   Initial
There will be a $25 charge for any NSF in addition to any charges from you financial institution.    Initial

I have read and understand the Terms of Acceptance, Financial and Office Policies and agree to the above terms. I also understand that the practice may amend the terms from time to time.
Signature

Clear
Date

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Date
Treatment of a Minor

For all services rendered to a minor, we will look to an adult to accompany the patient and for payment of any fees or services.
I Name being the parent or legal guardian of have read and fully understand the terms above and hereby grant my permission for my child to receive Chiropractic care.
Signature:

Clear
Date:

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AUTHORIZATION FOR HIPAA
Your authorization is requested for purposes of delivering your care in an open adjusting or open door adjusting environment as described in the office's privacy notice.

In the course of your care either of these environments may cause details of your condition and care to be disclosed to other patients or staff in the approximate vicinity of where your care is being delivered. We cannot assure that any of the details ofyour care will be addressed and considered as confidential by other patients.

This authorization has been requested by Darren J. Avise, Avise Chiropractic, PLLC. The purpose of this authorization is to allow for phone/reminders at home/ work and your signature on a sign in sheet.

We are requesting your authorization in these regards to assure that you are fully informed and in agreement with the method and circumstances in which we deliver chiropractic care. Your care will not be conditioned on your agreement to this authorization. You have the right to not sign this authorization and you also have the right to revoke this authorization at some time in the future please advise us accordingly in writing.

If you agree to this authorization copy will be maintained by this office and a copy will be provided to you.

Thank you for your cooperation and understanding.
Yes, I would like to receive the HIPAA rules and regulation guide.No, I do not wish to receive the HIPAA rules and regulation guide.
Signature:

Clear
Date:

MonthDayYear
Date
Please check this box if you are signing for a minor and tell us your relation to the minor below.
Relation with minor
Should be Empty:

Confidential Health Questionnaire

Health History

REVIEW OF SYSTEMS:

Automobile Accident History

Personal Injury Questionnaire

PATIENT INFORMATION

AT FAULT DRIVERS INFORMATION

Terms of Acceptance

AUTHORIZATION FOR HIPAA