Automobile Accident Questionnaire



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Automobile Accident Questionnaire

Please answer all questions completely


Dear Patient: This information is considered confidential. 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!

Marital Date of Number of

Name___________________________ Sex____ Status ______ Birth _____________Age ____ Children ____

SSN_____________ Home Phone _________________ Cell Phone _________________ Referred By_____________

Address___________________________________________ City____________________ State ______ Zip________

Company


Occupation____________________Name­­­­­­­­­­­­­­­­___________________Location_______________Phone#______________
Do you smoke? ____Yes ____No Consume Alcohol ____Yes ____No Are you: Right Handed or Left Handed ?
Email address: ______________________________________________ Today’s Date: _________________
Date of accident: ___________________ Time of accident: _________AM _________PM

Were you the: ___Driver; ___Front Passenger; ___Lt. Rear Passenger; ___ Rt. Rear Passenger

Were you wearing a seatbelt: ___Yes ___No

What street were you on at the time of the accident: ____________________________________________________

What city/town were you in at the time of the accident: __________________________________________________

What was the speed of your vehicle at the time of the accident: ___________________________________________

What was the speed of the vehicle that hit you at the time of the accident: ___________________________________

What was the make and model of the vehicle you were in: ________________________________________________

What was the make and mode of the vehicle that hit you: ________________________________________________
Where was your vehicle hit [check one]:
___Front; ___Rear; ___Right front; ___Right Center

___Right rear; ___Left front; ___Left center; ___ Left rear


If your vehicle was stopped, how far was it pushed as a result of the impact: _________________________________

At the point of the impact were you looking: ___ Forward; ___Right; ___Left

Were you [check one]: ___Aware of the impact; ___Surprised by the impact

Did you hit your head on impact: ___No ___Yes; if yes then on what: ______________________________________


Did any other body part hit anything in the vehicle: ___No ___Yes; if yes then please explain: ______________________________________________________________________________________________

Were you unconscious as a result of the injury: ___No ___Yes; if yes how long: ______________________________________________________________________________________________


Were you bleeding as a result of this injury: ___No ___Yes; if yes please describe: ______________________________________________________________________________________________
Please describe the pain you experienced immediately after the accident:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Since the injury are your symptoms ___Improving? ___Getting Worse? ___Same?

Did the police go to the accident: ___Yes ___No

Did you go to the hospital: ___ Yes ___ No
If yes what hospital ___________________________________________

Did you go to the hospital by ambulance: ___No ___Yes

If you drove to the hospital then the date_______________________ and time_________________________

At the hospital were x-rays taken: ___No ___Yes; If yes then of what _______________________________

_______________________________________________________________________________________

Were any other tests performed: ___No ___Yes; if yes then of what tests and the results

________________________________________________________________________________________

Was there any fractures seen on x-ray: ___ No ___Yes; if yes then where;___________________________

________________________________________________________________________________________

What were you told by the emergency room doctor at the hospital in regard to your

injuries. (what did he/she say happened to you) _________________________________________________

________________________________________________________________________________________


Have you seen any other doctor for these injuries: ___ No ___Yes

If yes, what is the doctors name: ______________________________________________________________


What was the doctor’s diagnosis: ______________________________________________________________

________________________________________________________________________________________

What was this doctors treatment: (list any medications given)________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Have you ever had any complaints in the involved area before? ____Yes ____No

If yes, what were the complaints? _________________________________________________________________
Before the injury were you capable of working on an equal basis with others your age? ____Yes ____No
Were you ever involved in a motor vehicle accident prior to this accident? ____Yes____No
If yes, How many?____

What was/were the date(s) of the accident(s)____________________________________________________

Were you injured from the accident? (If yes, explain)______________________________________________

Were you treated for the injuries? (If yes, where were you treated?)_________________________________

How long did you receive treatment?______________Did you have pain after the treatment?_____________
Describe your main area of pain:

_____________________________________________________________________

_____________________________________________________________________

Please mark your areas of pain on the figures below:



On a pain scale of 1-10 (with 0 = no pain and 10 being unbearable pain)

0__/__/__/__/__/__/__ /__/__/___/__10

1 2 3 4 5 6 7 8 9 10
What is the estimated percentage of time you experience the pain?

0% ____________/______________/______________/____________100%

(intermittent) 25%(occasional) 50% (frequent) 75% (constant)
Describe you second area of pain:

_____________________________________________________________________

_____________________________________________________________________
On a pain scale of 1-10 (with 0 = no pain and 10 being unbearable pain)

0__/__/__/__/__/__/__ /__/__/___/__10

1 2 3 4 5 6 7 8 9 10
What is the estimated percentage of time you experience the pain?

0% ____________/______________/______________/____________100%

(intermittent) 25%(occasional) 50% (frequent) 75% (constant)
Describe you third area of pain:

_____________________________________________________________________

_____________________________________________________________________
On a pain scale of 1-10 (with 0 = no pain and 10 being unbearable pain)

0__/__/__/__/__/__/__ /__/__/___/__10

1 2 3 4 5 6 7 8 9 10
What is the estimated percentage of time you experience the pain?0% ____________/______________/______________/____________100%

(intermittent) 25%(occasional) 50% (frequent) 75% (constant)

When your back hurts, you may find it difficult to do some of the things you normally do. Mark only the sentences that describe you today.
Because of my back:


  • I stay at home most of the time

  • I change position frequently to try and get my back comfortable

  • I walk more slowly than usual

  • I am not doing jobs that I usually do around the house

  • I use a handrail to get upstairs

  • I lie down to rest more often

  • I stay in bed most of the time

  • I have to hold on to something to get out of an easy chair

  • I try to get other people to do things for me

  • I get dressed more slowly than usual

  • I have trouble putting on my socks

  • I only stand up for short periods of time

  • I sit down for most of the day

  • I try not to bend or kneel down

  • My back is painful almost all of the time

  • I have trouble sleeping

  • I find it difficult to turn over in bed

  • My appetite is not very good

  • I only walk short distances

  • I am more irritable and bad tempered with people than usual

Check symptoms you have noticed since the accident:


____Headache ____Dizziness ____Depression ____Fatigue

____Stomach Upset ____Light Bothers Eyes ____Buzzing in Ears ____Diarrhea

____Neck Pain ____Head seems too Heavy ____Loss of Memory ____Feet Cold

____Neck Stiff ____Pins and Needles in Arms ____Ears Ring ____Hands Cold

____Fainting ____Sleeping Problems ____Loss of Balance ____Back Pain

____Face flushed ____Pins and Needles in Legs ____Constipation ____Tension

____Nervousness ____Numbness in Fingers ____Loss of Smell ____Fever

____Irritability ____Numbness in Toes ____Loss of Taste ____Chest Pain

____Cold Sweats ____Shortness of Breath

Vomiting: ___No ___Yes; if yes, explain ___________________________________________________________

Vertigo (room spins around you): ___No ___Yes

Bladder dysfunction: ___No ___Yes; if yes explain ____________________________________________________

Bowel dysfunction: ___No ___Yes; if yes explain _____________________________________________________
Are there any other problems you are experiencing since the accident?

____________________________________________________________________


If you have headaches circle the appropriate responses (see below for descriptions of ratings):
Front of Head: Grade – 1 2 3 4 Side – Right Left Both Frequency – 1 2 3 4

Side of Head: Grade – 1 2 3 4 Side – Right Left Both Frequency – 1 2 3 4

Back of Head: Grade – 1 2 3 4 Side – Right Left Both Frequency – 1 2 3 4
Grade:

1 = minimal, the pain is annoying but is forgotten during activities of daily living

2 = slight, the pain is tolerated, but it does interfere with some daily activities

3 = moderate, the pain extensively interferes with activities including sleep, recreation, etc.

4 = marked, the pain prevents most activities, including sleep, recreation, etc
Side: If your pain is in the front or back is it to the right, left or both sides? Grade each headache separately if it occurs in more than one area.
Headache pain frequency:
1 = I have intermittent symptoms occurring up to 25% of my awake time

2 = I experience occasional symptoms between 25-50% of the time

3 = Pain is frequent and occurs between 50-75% of the time

4 = I have constant pain occurring between 75-100% of my awake time




PERSONAL INJURY INSURANCE INFORMATION (REQUIRED)

Your Automobile Insurance Company:
Name of Company___________________________________________Phone____________________________
Address____________________________________________________________________________________
Claim #____________________________Has your insurance company been notified of the accident? Yes or No

**********************************************************************************************************************************


Driver Information (If you were not driving and the driver is the owner of the vehicle):
Name of driver_______________________________________________Phone___________________________
Address____________________________________________________________________________________
Driver’s Automobile Insurance Company (Only fill in if you were a passenger and do not have automobile insurance of your own)
Name of Company____________________________________________Phone___________________________
Address____________________________________________________________________________________
Policy #_____________________________Has the insurance company been notified of the accident? Yes or No

Your Health Insurance Information:
Name of Company______________________________________________Policy #________________________
Are you covered by Medicare? Yes or No If yes, what is your insurance number?_______________________
**********************************************************************************************************************************
Advising Attorney Information:
Name of Attorney_____________________________________________Phone___________________________
Address____________________________________________________________________________________
**********************************************************************************************************************************

Assignment of Benefits by a Patient to a Physician:
I hereby assign to my physician all benefits for such services to which I am entitled under my Personal Injury Protection and/or Medical Payments coverage, and request my insurance company to pay any such benefits directly to my physician upon submission of any claim.

Signed________________________________________________Date____________________________



Patient Information Form

Waltham Chiropractic Health Insurance Affidavit

In order for this office to process your claim efficiently, it is necessary to obtain the following information regarding other health benefits available to you.


Any medical expenses in excess of $2,000 will not be paid under your Auto policy if those expenses will be compensated, paid, or indemnified by an outside insurance carrier. Bills submitted to your Auto insurance carrier over the $2,000 limit must be accompanied by an explanation of benefits from your health carrier or a copy of this Affidavit.
If you have health insurance benefits through Mass Health ONLY, please complete Section One. For all other health insurance benefits, complete section two. If you do not have any health benefits available to you, please complete section 3.
Initial the Correct Box

Section ONE:



I hereby certify that I have Mass Health as a healthcare provider with NO other healthcare benefits available to me.

______________________________________________

MassHealth ID Number

Section TWO:



I hereby certify that I have the following health insurance benefits available to me:
Health Insurance Co: _______________________________________________________
Policy Number: ____________________________________________

Section Three:



I hereby certify this I do not have any accident and/or health benefits available to me through my own policy or that of a household member.

______________________________________________________ ________________________

Signature Date

Patient: __________________________________________________ DOB: ________________________


MVA Date: ____________________

Patient: ___________________________________________________________


Carrier 1: __________________________________________________________
Carrier 2: __________________________________________________________
Attorney: __________________________________________________________
RE: PATIENT RECORDS, IME REQUEST, PIP Application and DOCTOR’S LIEN
I do hereby authorize Waltham Chiropractic to furnish my Attorney/Insurance carrier, with a full report of my case history, examination, diagnosis, treatment, and prognosis in regard to my accident/illness which occurred/began on ____________.
I also authorize and request my Attorney/Insurance company to send any IME report, PIP Application or request for me to attend an IME to Waltham Chiropractic.
I hereby give a lien to said Doctor on any settlement, claim judgment, or verdict as a result of said accident/illness, and authorize and direct you, my Attorney/Insurance carrier, to pay directly to said Doctor such sums as may be due and owing him for service rendered me, and to withhold such sums from such settlement, claim, judgment, or verdict as may be necessary to protect said Doctor adequately.
I understand that I am directly and fully responsible to said Doctor for all Chiropractic bills submitted by him for service rendered me, and that some procedures may not be covered by my health insurance, and that this agreement is made solely for said Doctor’s additional protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, claim, judgment, or verdict by which I may eventually recover said fee.
Dated: ____________________ Signature: ____________________________________
The undersigned, being Attorney of record or authorized representative of insurance carrier for the above patient does hereby acknowledge receipt of the above lien, and does agree to honor the same to protect adequately said above named Doctor.
Dated: _______________________ Authorized signature: _________________________
Autorizo a mi Doctor Quiropractico para proveer cualquier clase de informacion relacionada con mi case, a mi abogado/Compania de Seguros. Authorizo a mi abogado/Compania de seguros para pagar directamente a mi Doctor. Estoy informado de que soy responsable por pagar mes cuentas medicasopracticas. El pago de mis cuentas no esta basado en ningun caso judicial o verdicto.
Waltham Chiropractic

136 Bacon Street

Waltham, MA 02451

Dr. John Duffy


INFORMED CONSENT

When a patient seeks chiropractic care and when a chiropractor accepts a patient for such care, it is essential that they both be seeking the same goals. The practice of chiropractic in this office consists of analysis and adjustment of the spine for the purpose of locating and correcting vertebral subluxations. (spinal misalignments causing nerve interference). We also strive to educate and encourage our patients/practice members to become aware of and responsible to their well being.

Our intention is to provide you with the best care we can offer as outlined above. We do not offer care with the intent of “treating” or “curing” diseases or conditions.

Physicians, chiropractors, osteopaths and physiotherapists using manual manipulation are required to advise their patients that there have been rare incidents of injury to the vertebral artery during the course of treatment. There have caused strokes or stroke-like occurrences which are usually of a temporary nature. The chances of this happening are approximately 1 in 3 million treatments. There have also been rare incidents of rib bruising or swelling of aggravation of symptoms. Appropriate tests will be performed on you to minimize your risks.

It is important that you understand that chiropractic care involves a “hands on” approach. During the delivery of a chiropractic adjustment or diagnostic procedure, there may be physical contact made in possibly sensitive areas. By signing below you are acknowledging that you have been informed of and consent to the type of care you will receive and that you have been made aware of any risks inherent in that care. You also acknowledge that you have been made aware of other treatment options. If a change in approach, additional testing, and referrals to other providers or a need to apply care requiring a different touch is required it will be discussed with you prior to it being administered. If at any time you are in any way uncomfortable with any aspect of the care that you are receiving, please do not hesitate to let us know.

Our practice is based on the simple truth that if we satisfy and delight our patients, they will get well faster and be more likely to tell others about their chiropractic experience. Since chiropractic results vary, we can’t guarantee results, but we can promise your satisfaction. Within 3 days of beginning care, if you are not completely happy with your decision to begin chiropractic care in this office, we will happily refund the money you’ve paid us.


I/We understand and consent to care at Waltham Chiropractic for myself/my family, as outlined in this “Informed Consent”.
Signed: ____________________________________ Name (print) ______________________________

Date: _______________


Waltham Chiropractic

136 Bacon St.

Waltham, MA 02451
Cancellation Fees & Agreement
The staff at Waltham Chiropractic takes the time to treat all patients as efficiently as possible. In order to do that, we schedule appointments so that patients can be seen and treated in a timely manner. In order to maintain a proper schedule, we must now enforce a cancellation policy to all patients.
If you cancel an appointment less than 24 hours prior to it, or you do not show up for the appointment, you will be charged a $15 fee. This fee is waived if you make up that appointment within a week.
Please note scheduling an appointment is required. If you walk in for an appointment we cannot guarantee you will be seen immediately.

I, _______________________________, understand that I will be charged a $15 fee for any scheduled appointment that I cancel with less than 24 hours notice, or do not show up for.

____________________________________ ____________________

SIGNED DATE

____________________________________ ____________________



STAFF WITNESS DATE




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