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Automobile Accident
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Medpay/Major Medical Insurance Information
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Insurance Company
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Name of Agent
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Phone
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Address
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City
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State
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Zip Code
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Claim Number
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Policy Number
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Amount ($1000/$5,000) (call insurance company for amount)
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Other Cars
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Insurance Company
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Name of Agent
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Phone
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Address
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City
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State
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Zip Code
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Claim Number
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Policy Number
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Attorney
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Firm
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Name
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Phone
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Fax
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Email:
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Address
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City
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State
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Zip Code
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Accident History and Report
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Date of Accident
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Time of Accident (AM or PM)
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State occurrence of accident in your own words
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Was an accident report filed?
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Police of city:
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State
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County:
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Who was ticketed?
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Reason:
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Vehicle Information
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Color, Make, Model, and Year of Vehicle
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Owner of Vehicle:
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Condition of car prior to accident
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Damage done inside of car
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Damage done outside of car
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Other damages
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Did you strike another car?
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Where?
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What type of vehicle was involved in the accident?
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If other, please describe
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Do you have pictures of any other vehicles involved?
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People In Vehicle
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Driver Seat
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Passenger Seat
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Back Left
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Middle
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Right
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Other
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Accident Details
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Were you rotated in your seat?
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Was your seat reclined?
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Was your seatbelt on?
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Fastened and worn correctly?
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Were you tired?
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Were you sleeping?
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Did your vehicle go off the road?
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Do you remember the impact?
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Were you completely conscious after impact?
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Does it bother you to ride in a car now?
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Time of Day
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Type of Road
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Where car was hit
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Where
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Position of Head Rest
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Posted Speed Limit
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Your Speed
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Weather Conditions
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Traffic Conditions
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Duration in car before accident occured
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Location prior to accident
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Any strange events during or after accident:
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Lost time for work/school?
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If yes, please state from when to when
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Have you received medical attention before coming here?
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What type?
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Please Draw the Accident
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Mark Pain Area
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Was there a passenger in your Vehicle?
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General Symptoms
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Did you hit any part of your body during the collision?
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If yes, Where? (e.g Head on Dash)
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Were you taken to the hospital?
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If yes, for how long?
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Did you receive care from any other health care specialist?
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If yes, who?
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What type of care were you given? For how long?
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Where do you feel pain?
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What are your current symptoms?
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Have you ever been injured in a similar manner?
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If yes, how and when?
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Do you remember the impact?
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Does it bother you to be in a car now?
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Were you completely conscious after the impact?
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Were you tired?
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Were you sleeping?
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How long were you in the car?
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Where were you prior to the accident?
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Have you had any time loss from work or school?
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If yes, please state how long with dates.
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Please Draw the Accident
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Client Re-Exam Form
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Primary objective when you began care?
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Do you feel like the doctor clearly understands your problem?
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If no, please explain
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Noticed Improvement
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Better able to handle stress
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Better sleep
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Increase muscular strength
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More alert
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More energy/vitality
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Better memory/concentration
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Better emotional control
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Improved overall mood
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Improved coordination
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Improved hearing
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Improved Vision
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Improved Balance
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Normal Blood Pressure
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Improved Bowel Movements
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Improved Bladder Function
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Better Digestion
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Decreased Sinus Congestion
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Improved Learning Abilities
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Decreased Back Pain
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Decreased Headaches
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Less/no medications
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Improved Circulation
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Improved Allergies
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Fewer colds and flu
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Increased Flexibility
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Less/no tingling
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Decreased Neck Pain
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Improved Posture
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Decreased Depression
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Ability to exercise
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Less/no heartburn
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Restless Leg Syndrome
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Women
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More Regular Cycles
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More comfortable cycles
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Improved Fertility
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Improved sexual function
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Children
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Improved colic
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Less/no earaches
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Decreased bed-wetting
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Improved behavior
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Men
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Reduced Prostrate Irritation
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Easier urination
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Improved Fertility
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Reduced Prostrate Irritation
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What health gains are you most excited about?
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A:
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B:
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C:
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Please circle your level of progress to date for each original complaint
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Original Complaint:
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Level of Progress
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Original Complaint:
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Level of Progress
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Original Complaint:
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Level of Progress
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Original Complaint:
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Level of Progress
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Original Complaint:
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Level of Progress
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Select how satisfied you are with the overall improvement(s) you have experienced to this point of care.
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Nutrition
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Are you following your current food allergy test restrictions?
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What is your big win?
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What is the struggle?
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Are you taking our recommended supplements?
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What is your big win?
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What is the struggle?
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Have you implemented the nutritional changes?
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What is your big win?
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What is the struggle?
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Are you using the online meal plan system?
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What is your big win?
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What is the struggle?
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Are you experiencing any detox systems?
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What is the struggle?
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What is your big win?
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Any additional comments/questions you'd like us to further discuss regarding your nutrition?
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Are you doing the daily mobility exercises?
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What is the struggle?
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What is your big win?
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Worker's Compensation History
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Employer Information
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Company
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Employer's Name
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Phone
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Address
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City
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State
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Zip Code
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Policy Holder
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Policy Holder's Name
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Phone
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Address
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City
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State
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Zip Code
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Attorney
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Firm
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Name
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Phone
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Fax
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Email:
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Address
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City
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State
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Zip Code
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Injury Description
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Was injury immediately reported to proper authorities?
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Date present injury was received:
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Time of Injury (AM/PM)
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Overtime
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Name and Title of Witness
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Name and Title of Witness
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Name and title of who reported the accident
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What medical attention was rendered:
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By whom was medical attention given:
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Chief Complaint:
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Symptoms
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Since the injury are your symptoms:
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How did the injury occur?
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Job Requirements
• • •
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Frequent movements
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Use of Machine
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Type
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Picking up or lifting
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Type
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Please describe job conditions in greater detail
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Job Conditions
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Type of building
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Type of windows
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Type of floor
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If other, please describe
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Type of ventilation
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If other, please describe
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Type of lighting in the building
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If other, please describe
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Are you tired when you go home at night?
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Do you have outside jobs?
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If other, what type?
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Do you participate in any company sponsored programs such as exercise, sports, etc?
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If yes, describe
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Type of shop
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Has outside help been hired?
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If yes, please describe
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How many employees are in the plant?
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How many employees per shift?
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How many employees do your job?
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What is the current injury ratio for that job?
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How many employees have been injured doing your job?
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Do you like your job?
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If off work, do you want to return to your job?
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What changes would you make to your job?
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Present Work History
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What is the classification of your normal job?
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Were you performing your normal job?
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What shift were you working?
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How long have you been at your present job?
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Time loss or absence caused from job injury?
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If yes, please explain
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Average Work Week
/
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Description of Past Jobs in the Last 10 Years
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#1
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#2
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#3
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#4
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#5
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Was a pre-employment exam performed or required?
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If yes which jobs, listed above?
• • •
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Date, Doctor, and Place
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Date, Doctor, and Place
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Date, Doctor, and Place
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Have you ever applied for Worker's Compensation Benefits before?
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If yes, please provide the date
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Reason
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Was there a time loss from work?
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If yes, please state the date
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State the degree of recovery
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Did you retain legal counsel for these injuries?
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Company
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Name
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Address
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City
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State
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Zip Code
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Mark Pain Area
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