|
PATIENT INFO
|
|
|
Marital Status
|
|
|
Employer
|
Occupation
|
|
City
|
State
|
|
ZIP
|
Phone
|
|
Spouse or parent's name
|
|
|
SYMPTOMS
|
|
|
Main Complaint
|
How often?
|
|
How bad?
|
Is it getting worse?
|
|
When did it start?
|
What activity bothers it the most?
|
|
Getting better?
|
When is it at its worst?
|
|
When is it at its best?
|
|
|
Rate the pain
|
|
|
Other Chiropractors
|
Positive experiences
|
|
Other type of physician or therapist
|
Positive experiences
|
|
Secondary Complaint
|
|
|
Health History (select all that apply)
• • •
|
|
|
WOMEN ONLY
|
Are you a woman?
|
|
How many children?
|
Are you pregnant?
|
|
Date of last Menstrual Cycle
|
Nursing details
|
|
Are you taking birth control pills?
|
|
|
Previous Surgeries and Dates
|
|
|
What kind of exercise do you do?
|
What supplements do you take?
|
|
How much do you smoke per day?
|
How much do you drink per day?
|
|
Signature
|
|
|
Below questionnaire only to be filled by existing patient
|
|
|
LOW BACK PAIN
|
Low Back Pain Disability Questionnaire
|
|
Section 1 – Pain intensity
|
Section 2 – Personal care (washing/dressing etc)
|
|
Section 3 – Lifting
|
Section 4 – Walking
|
|
Section 5 – Sitting
|
Section 6 – Standing
|
|
Section 7 – Sleeping
|
Section 8 – Sex life (if applicable)
|
|
Section 9 – Social life
|
Section 10 – Travelling
|
|
SCORE
|
|
|
NECK PAIN
|
Neck Pain Questionnaire
|
|
Section 1 – Pain Intensity
|
Section 2 – Personal Care
|
|
Section 3 – Lifting
|
Section 4 – Reading
|
|
Section 5 – Headache
|
Section 6 – Concentration
|
|
Section 7 – Work
|
Section 8 - Driving
|
|
Section 9 – Sleeping
|
Section 10 – Recreation
|
|
SCORE
|
|
|
EVIDENCE OF FUNCTIONAL IMPROVEMENT...
|
|
|
Evidence of Functional Improvement
|
Date of Injury
|
|
...in regards to WORK activities:
|
|
|
Since the most recent evaluation...
|
|
|
A. Ability to work has
|
B. Work restrictions have
|
|
C. Work output has
|
|
|
D. Currently unable to do any work
|
Currently on modified work duty
|
|
E. Current work restrictions
|
If yes, specify
|
|
F. Currently working fewer hours
|
How many hours currently working?
|
|
Additional information
|
|
|
...in regards to HOME/SCHOOL/REC Activities:
|
|
|
Since the most recent evaluation
|
|
|
A. Ability to lift has
|
B. Ability to Sit longer has
|
|
C. Ability to stand longer has
|
D. Ability to walk further has
|
|
E. Ability to use arms and hands has
|
F. Ability to do recreational activities has
|
|
G. Ability to do usual exercise routine
|
H. Ability to care for your children
|
|
Additional information
|
|
|
...with CORRECTIVE EXERCISES
|
|
|
With exercise rehab, since the last evaluation
|
|
|
A. Neck strength has
|
B. Low back strength has
|
|
C. Abdominal strength has
|
|
|
D. Strength has
|
Which part?
|
|
E. Strength has
|
Which part?
|
|
Additional information
|
|
|
REHAB PROGRESS (percent of goal obtained)
|
|
|
Neck
|
Back
|
|
Abs
|
|
|
DISABILITY INDEXES
|
|
|
Disability Indexes, please select
• • •
|
Other functional changes noted
|
|
AUTO ACCIDENTS
|
Auto Accident?
|
|
Please Read
|
|
|
Policyholders Name
|
Insurance Company's Name
|
|
Policy #
|
Claim #
|
|
Med-Pay Coverage?
|
Amount $
|
|
Adjuster's Name
|
Phone #
|
|
Claims office address
|
|
|
What was the date of the accident?
|
What time did the accident occur?
|
|
How many vehicles were involved in the accident?
|
|
|
What was the estimated damage to the vehicle you were in?
|
|
|
What state did the accident occur in?
|
What city did the accident occur in?
|
|
What street or intersection were you on when the accident occurred?
|
|
|
What direction were you traveling in?
|
|
|
What type of impact was the auto accident?
|
|
|
Vehicle hit anything after the accident?
|
If yes, please describe
|
|
Where were you sitting in the vehicle during the accident?
|
|
|
Did you know the accident was coming?
|
What type of vehicle were you in?
|
|
What type of vehicle impacted yours?
|
|
|
At the time of impact, how fast was the vehicle moving?
|
|
|
At the time of impact, how fast was the other vehicle moving?
|
|
|
During/after crash what happened to your vehicle?
• • •
|
Lose consciousness during the accident?
|
|
How was your head positioned during the accident?
|
|
|
How was your torso positioned during the accident?
|
|
|
How were your hands positioned during the accident?
|
|
|
Head hit anything during the accident?
|
If yes, please describe
|
|
Face hit anything during the accident?
|
If yes, please describe
|
|
Shoulders hit anything during the accident?
|
If yes, please describe
|
|
Neck hit anything during the accident?
|
If yes, please describe
|
|
Chest hit anything during the accident?
|
If yes, please describe
|
|
Hips hit anything during the accident?
|
If yes, please describe
|
|
Knees hit anything during the accident?
|
If yes, please describe
|
|
Feet hit anything during the accident?
|
If yes, please describe
|
|
What kind of headrest was in your vehicle?
|
|
|
Where was the headrest positioned on your head?
|
|
|
Have your seatbelt on during the accident?
|
What was damaged in your vehicle?
• • •
|
|
Items that denied inward
• • •
|
Doors that would not open due to accident?
• • •
|
|
Did you go to the hospital?
|
If no, why?
|
|
How did you get to the hospital?
|
What was the name of the hospital?
|
|
Were you hospitalized overnight?
|
What you were prescribed at the hospital?
• • •
|
|
Stitches for any cuts at the hospital?
|
|
|
Were x rays taken at the hospital?
|
If yes, which area was taken
|
