The Way to Wellness - TwWebDev.com

1 Health Moves "The Way to Wellness " PATIENT INFORMATION Today s Date Name Age Birthdate Address City State Zip Home Phone Work Phone Cell Phone Fax Sex: M F Email SSN Marital Status: Single Married Divorced Widowed Separated Occupation Employer (Name & Address) Emergency Contact Phone Number Who may we thank for referring you to our office? INSURANCE INFORMATION Name of your insurance company (regardless of fault) Claims Address City State Zip Phone Number Medical Claims Adjuster s Name Claim Number Name of the Driver of the Other Vehicle Their Insurance Company Policy Number PERSONAL INJURY QUESTIONNAIRE am pm Date of Accident: Time of Day: Were the police notified?

2 Yes No If yes, investigation by Were there any witnesses? Yes No Names Have you retained an attorney? Yes No Name Phone Number Were you Driver Passenger Front Seat Back Seat Number of people in your vehicle Number of people in other vehicle Did your air bag deploy? If so, which one(s)? Road conditions at time of accident: Wet Dry Icy Other Road surface: Asphalt Gravel Dirt Other What direction were headed? N S E W Name of street What direction was the other vehicle headed? N S E W Name of street 17311 135th Ave. NE, Ste. C-800 Woodinville, WA 98072 (425) 402-9999 1 Were you struck from: Behind Front Left Side Right Side Were you wearing a seatbelt? No Yes If yes: Lap Belt Only Shoulder and Lap Shoulder Belt Only Any bruising or soreness from the seat belt?

3 No Yes, explain What was your position at the time of impact? Facing Straight Ahead Head Turned Right Left Does your car have a headrest? No Yes If yes, approximately how far was the top of the headrest from the top of your head? inches Above Below Were you knocked unconscious? No Yes If yes, for how long? Were you aware of the approaching collision prior to impact? No Yes If yes, did you try to brace yourself prior to impact? No Yes, How? Was your car stopped at the time of impact? No Yes If yes, was the driver s foot on the brake pedal? No Yes Clutch pedal? No Yes If yes, did your car move forward upon impact? No Yes If no, were you: Gaining Speed Slowing Down Traveling Steady Rate of Speed: Slow Medium Fast Did your vehicle strike another car?

4 No Yes Did your vehicle strike another object? No Yes, Was the other vehicle moving at the time of collision? No Yes If yes, at the time of impact was the other vehicle traveling: Slow Medium Fast If yes, was the other vehicle: Gaining Speed Slowing Down Traveling at a Steady Speed What type of car were you driving? What type of car impacted with your vehicle? In your own words, please describe the accident (include what you saw or felt): Describe how you felt (did you feel pain): DURING the accident: IMMEDIATELY AFTER the accident: LATER THAT DAY: THE NEXT DAY: Other: What is the estimated cost of damage to your vehicle? Do you have a photo of the damage? [ ] No [ ] Yes On what part of the automobile did the following body parts hit? Head Hit: Chest Hit: Right/Left Shoulder Hit: Right/Left Arm Hit: Right/Left Hip Hit: Right/Left Leg Hit: Right/Left Knee Hit: Other: 17311 135th Ave.

5 NE, Ste. C-800 Woodinville, WA 98072 (425) 402-9999 2 Which of the following car parts broke during the accident? Windshield Front Seat Back Right/Left Side Window Steering Wheel Other: Did you have any physical complaints BEFORE THE ACCIDENT? No Yes, describe in detail: What are your PRESENT complaints and symptoms? Do you have any congenital (from birth) factors that relate to this problem? No Yes, explain: Do you have any previous illnesses relating to this case? No Yes, Have you ever been involved in an accident before? No Yes If yes, describe including date(s), type(s) of accidents and injury(s) received: Did you receive medical care immediately following the accident? No Yes If yes, describe where, type of treatment and doctor s name: Have you been treated by another doctor since the accident? No Yes If yes, list the doctor s name, address and phone: What type of treatment did you receive?

6 Since this injury occurred are your symptoms: Improving Getting Worse Same CHECK SYMPTOMS THAT YOU HAVE NOTICED SINCE THE ACCIDENT: Face Flushed Cold Sweats Depression Nervousness Feet Cold Hands Cold Headache Neck Pain Neck Stiffness Upper Back Pain Mid-Back Pain Lower Back Pain Hip Pain Knee Pain Foot Pain Shoulder Pain Elbow Pain Wrist Pain Arm Pain Leg Pain Chest Pain Loss of Taste Memory Loss Loss of Balance Loss of Smell Dizziness Fainting Fever Ears Ringing Irritability Fatigue Diarrhea Constipation Sleeping Problems Head Seems too Heavy Pins & Needles in Arms Pins & Needles in Legs Numbness in Fingers Numbness in Toes Shortness of Breath Light Bothers Eyes Emotions out of Control Symptoms other than above: 17311 135th Ave. NE, Ste. C-800 Woodinville, WA 98072 (425) 402-9999 3 Employer: Type of Employment: Have you lost time from work as a result of this accident?

7 No Yes If yes, when was the last day you worked? Number of days missed: If yes, are you being compensated for time lost from work? No Yes, type of compensation you are receiving: Do you notice any activity restrictions in your capacity for work, family or recreational pursuits as a result of this injury? [ ] No [ ] Yes If yes, describe in detail: Other pertinent information: Date: Patient s Signature: PAIN RATING AND LOCATION SCALE MY CHIEF COMPLAINT IS: 2nd COMPLAINT: 3rd COMPLAINT: PLEASE DRAW THE LOCATION AND TYPE OF PAIN ON THE BODY OUTLINES: Ache Burning Numbness MMMM OOOOO NNNNN Pins and Needles Stabbing Other / / / / / XXXXX 17311 135th Ave. NE, Ste. C-800 Woodinville, WA 98072 (425) 402-9999 4 FUNCTIONAL RATING INDEX In order to properly assess your condition, we must understand how much your pain has affected your ability to manage everyday activities.

8 For each item below, please circle the number which most closely describes your condition right now. 1. PAIN INTENSITY 0 1 2 3 4 No Mild Moderate Severe Worst Pain pain pain pain pain 2. SLEEPING 0 1 2 3 4 Perfect Mildly Moderately Greatly Totally sleep disturbed disturbed disturbed disturbed sleep sleep sleep sleep 3. PERSONAL CARE 0 1 2 3 4 No Mild Moderate Moderate Severe pain; pain; no pain; need pain; need pain; need no restrictions restrictions to go slowly some 100% assistance assistance 4. TRAVEL 0 1 2 3 4 No pain Mild pain Moderate Moderate Severe on long on long pain on pain on pain on trips trips long trips short trips short trips 5. WORK 0 1 2 3 4 Can do usual Can do Can do Can do Cannot work plus usual work; 50% of 25% of work unlimited no extra usual usual extra work work work work 6.

9 RECREATION 0 1 2 3 4 Can do Can do Can do Can do Cannot do all activities most some a few any activities activities activities activities activities 7. FREQUENCY OF 0 1 2 3 4 PAIN No pain Occasional Intermittent Frequent Constant pain; 25% pain; 50% pain; 75% pain; 100% of the day of the day of the day of the day 17311 135th Ave. NE, Ste. C-800 Woodinville, WA 98072 (425) 402-9999 5 8. LIFTING 0 1 2 3 4 No pain Increased Increased Increased Increased with any pain with pain with pain with pain with heavy heavy moderate light any weight weight weight weight weight 9. WALKING 0 1 2 3 4 No pain Increased Increased Increased Increased any distance pain after pain after pain after pain with 1 mile miles miles all walking 10. STANDING0 1 2 3 4 No pain after Increased Increased Increased Increased Several hours pain after pain after pain after pain with Of standing several hours 1 hour hour any standing The starred items below must be filled out in order to obtain prior-authorization for acupuncture from your insurance company.

10 Rate your pain level on a scale of 1-10 (10 is the worst pain): *Rate your pain prior to starting treatments:* Rate your pain after starting treatments:* Please list ways your treatments are improving your symptoms ( frequency, intensity and ability to perform daily activities):_How many hours can you currently work? hours per day hours per week What dates were you unable to work at all to What dates did you work with limited work capacity to How many hours were/are you able to work? hours per day 17311 135th Ave. NE, Ste. C-800 Woodinville, WA 98072 (425) 402-9999 6 What is the main reason for your visit today? Other conditions / concerns for future discussion? Other Healthcare Providers: Dr. for Dr. for Dr. for Dr. for Dr. for Dr. for Medications / Supplements Medication Allergies Name Dose Name Dose Name Dose Name Dose Name Dose Name Dose Name Dose Name Dose Name Dose Name Dose None Drug Reaction Drug Reaction Drug Reaction Drug Reaction Drug Reaction Drug Reaction Drug Reaction Drug Reaction Drug Reaction Drug Reaction 17311 135th Ave.