Part 2: Patient Intake *First Name: *Last Name: *Email: *Age: *Birth Date: *Sex: Male Female Marital Status: Single Married Minor Partner Seperated Divorced Widow Other *Address: *City: *State: *Zip: *Cell Phone: Home Phone: Work Phone: Employment Status: Employed Retired Self-Employed Student Unemployed Employer / School Name: Occupation: Employer Address: Employer City: Employer State: Employer Zip: Brief Work Activity Description: Nearest Relative: Relation to you: Their Phone Number: Emergency Contact: Phone Number: Referred By: Google Ad Waze Tik Tok Google Web Search Instagram Existing JFTHOI Patient If referred by existing patient: If referred by something other than the above Reason For This Visit: Illness Injury Job Related Injury Auto Accident Check Up Other How do you intend to pay: Cash Credit Card Insurance Medicare Worker's Compensation Auto Accident Other What are your injuries or complaints?: Who have you seen for these injuries so far: When did these injuries start: What activities aggravate your condition:Have you seen a chiropractor before? Yes No How many years have you been seeing if yes? Description of sports, hobbies and daily activities: List all forms of exercise: How many glasses of water do you drink a day? List all medications / supplements taking:Previous car accidents? Yes No How many years since your last car accident? Serious Illness / Hospitalizations / Surgeries? Yes No Please check whether you have the following symptoms now or in the past. Dizziness (Now) Dizziness (Past) Headache (Now) Headache (Past) Allergies (Now) Allergies (Past) Depression (Now) Depression (Past) Knee Pain (Now) Knee Pain (Past) Ankle Pain (Now) Ankle Pain (Past) Hip Pain (Now) Hip Pain (Past) Numbness (Now) Numbness (Past) Tingling (Now) Tingling (Past) Tmj Pain (Now) Tmj Pain (Past) Anemia (Now) Anemia (Past) Alcoholism (Now) Alcoholism (Past) Fatigue (Now) Fatigue (Past) Sciatica (Now) Sciatica (Past) Spinal Curvatures (Now) Spinal Curvatures (Past) Swollen Joints (Now) Swollen Joints (Past) Colon Trouble (Now) Colon Trouble (Past) Difficult Digestion (Now) Difficult Digestion (Past) Hemorrhoids (Now) Hemorrhoids (Past) Asthma (Now) Asthma (Past) Deafness (Now) Deafness (Past) Ear Noises (Now) Ear Noises (Past) Enlarged Thyroid (Now) Enlarged Thyroid (Past) Stroke (Now) Stroke (Past) Diabetes (Now) Diabetes (Past) Ulcers (Now) Ulcers (Past) Tuberculosis (Now) Tuberculosis (Past) Bruise Easily (Now) Bruise Easily (Past) Hay Fever (Now) Hay Fever (Past) Nosebleeds (Now) Nosebleeds (Past) Sinus Infections (Now) Sinus Infections (Past) High Blood Pressure (Now) High Blood Pressure (Past) Low Blood Pressure (Now) Low Blood Pressure (Past) Pain Over Heart (Now) Pain Over Heart (Past) Poor Circulation (Now) Poor Circulation (Past) Rapid Heart Beat (Now) Rapid Heart Beat (Past) Chest Pain (Now) Chest Pain (Past) Polio (Now) Polio (Past) Bursitis (Now) Bursitis (Past) Difficulty Breathing (Now) Difficulty Breathing (Past) Pleurisy (Now) Pleurisy (Past) Cancer (Now) Cancer (Past) Itching (Now) Itching (Past) Varicose Veins (Now) Varicose Veins (Past) Bed-Wetting (Now) Bed-Wetting (Past) Frequent Urination (Now) Frequent Urination (Past) Kidney Infections (Now) Kidney Infections (Past) Prostate Trouble (Now) Prostate Trouble (Past) Cramps/Backache (Now) Cramps/Backache (Past) Excessive Menses (Now) Excessive Menses (Past) Hot Flashes (Now) Hot Flashes (Past) Rashes / Skin Lesions (Now) Rashes / Skin Lesions (Past)List Typical Breakfast FoodsList Typical Lunch FoodsList Typical Dinner FoodsList Typical Snacks & Beverages List Hours of Sleep: Tobacco Use: Yes No Cups of Coffee: List All Types Of Exercise: Alcohol Use: Yes No Drug Use: Yes No HAVE YOU BEEN IN A WORK RELATED INJURY? Workers Comp Claim # Adjusters Name: State Of Accident: Have you seen another provider for this injury? MOTOR VEHICLE ACCIDENT CLICK TO SKIP IF YOU ARE NOT IN FOR A CAR ACCIDENT Patient Full name: Date Of Accident: Time Of Accident: Please describe the accident in your own words:Were you the: Driver Front Passenger Rear Passenger Pedestrian How many people were in the accident vehicle: ACCIDENT SITE Road/Street Name: City/State: Nearest intersection with road/street: Which direction were you headed: Speed you were traveling: Driving Conditions: Dry Wet Icy OtherIMPACT Did your car impact another vehicle: Yes NoDid your car impact a structure: Yes No If yes, explain:Did any part of your body strike anything in the vehicle? Yes No If yes, explain:Was impact from: Front Rear Left Right OtherAt the time of impact were you: Looking straight ahead Looking to the left Looking up Looking to the right Looking DownWere both hands on the steering wheel: Yes NoIf no, which hand was on the wheel: Right LeftWas your foot on the brake: Yes NoIf yes, which foot was on the brake: Right LeftWere you: Surprised by impact Braced for impactVEHICLE Make and model of vehicle you were in:Were you wearing a seatbelt: Yes NoIf yes, what type: Lap ShoulderWas vehicle equipped with airbags: Yes NoIf yes, did it inflate properly: Yes NoDid your seat have a headrest: Yes NoIf yes, what was the position of the headrest: Low Mid HighOTHER VEHICLE Make and model of other vehicle: Which direction was other vehicle headed: Speed other vehicle was traveling:POLICEDid the police come to the accident site: Yes NoAny Witnesses: Yes NoPolice report filed: Yes NoWas a traffic violation issued: Yes No If yes, to whom?PATIENT CONDITIONWere you unconscious immediately after the accident: Yes No If yes, how long? Please describe how you felt immediately after the accident:TREATMENTDid you go to the hospital: Yes NoWhen did you go if so: Immediately after the accident Next Day 2 days or more after the accidentHow did you get to the hospital: Ambulance Private Transportation Name of hospital: Name of doctor: Diagnosis: Treatment received: X-rays taken:SYMPTOMS/INJURIESHave you been able to work since this injury: Yes No How many work days have you missed:Prior to the injury were you able to work on an equal basis with others your age: Yes NoMark any of the following symptoms you've had since your injury: ARM/SHOULDER PAIN BACK PAIN BACK STIFFNESS CHEST PAIN DIZZINESS EAR BUZZING EAR RINGING FATIGUE FEET/TOE NUMBNESS HAND/FINGER NUMBNESS HEADACHES IRRITABILITY JAW PROBLEMS LEG PAIN MEMORY LOSS NAUSEA NECK PAIN NECK STIFF SHORTNESS OF BREATHE SLEEP DIFFICULTY STOMACH UPSET TENSION VISION BLURREDIs this condition getting progressively worse: Yes No Unknown What areas of your body do you continue to have pain, numbness, or tingling? Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)Type Of Pain: Sharp Aching Cramps Dull Shooting Stiffness Throbbing Burning Swelling Numbness Tingling Other: How often do you have this pain? Is it constant or does it come and go?Does it interfere with your: Work Sleep Daily Routine RecreationMovements that are painful to perform: Sitting Standing Walking Bending Lying DownMOTOR VEHICLE ACCIDENT QUESTIONNAIREHave you continued to do any of the following activities despite the pain caused by your collision?WORKWhy have you continued to work? I Would Lose My Job If I Took Time Off I Couldn'T Support My Family Otherwise I Don'T Believe In Taking Time Off Even When I Am Injured Or In Pain My Business Would Fail If I Did Not Work I Cannot Take Time Off, Because I Care For My Own Children Other:I have experienced the following changes in my ability to perform at work: Mobility / Stability Problems Climbing Kneeling Lifting Walking For Long Periods Dexterity Problems Finger Movements Wrist Movements Postural Difficulties Problems With Tinnitus Or Ringing Of The Ears Standing For Long Periods Problems With Anxiety / Depression Problems With Vertigo Or Spinning Sensations Stooping Dizziness Sensations Of Whirling Motion Sensations Of Irregular Motion Giddiness Sitting For Long Periods Pain If Pain, where? Problems with reduced concentration? Can't Concentrate Can't think properly Making Mistakes Duration of symptoms: I experienced problems doing my normal work activities If so, how long? My doctors have instructed me that my inability to perform my normal pre-accident work activities without pain is a permanent condition My problems in performing my normal work activities are ongoing, but my doctor have not instructed me that the conditions are permanent DOMESTIC DUTIES:I have experienced pain while performing the following activities inside my home but have done them anyway: Laundry Cleaning Dishwashing Washing Windows Vacuuming Preparing Meals Other:Due to my injuries, I have brought in the following assistance: Paid Housekeepr Unpaid Assistance NoneMy family status would be described as: Single Single parent at home Spouse only Spouse and children at home I have the following number of children:The number of my children in the following age category is: Number of children 0-5 years: Number of children 5-11 years: Number of children 11+ years:Duration of Symptoms: [choose 1] I experienced problems doing my normal domestic activities How many weeks if so? My doctors have instructed me that my inability to perform my normal pre-accident domestic activities without pain is a permanent condition. My problems in performing my normal domestic activities is ongoing, but my doctors have not instructed me that the conditions is permanent Household:I have experienced problems with the following activities outside my home: Washing Windows Landscaping Mowing The Grass Trimming The Bushes/Trees Gardening Washing The Cars Maintaining The Cars Maintaining Yard Equipment Doing Other External Housework Taking Out The Trash Specify Other:Duration of symptoms: I experienced problems doing my normal household activities for weeks How many weeks? My doctors have instructed me that my inability to perform my normal pre-accident household activities without pain is a permanent condition My problems in performing my normal household activities are ongoing, but my doctors have not instructed me that the conditions are permanent Studies / Educational Duties: Carrying Books Sitting in classes Looking down to read Specify Other:I have also experienced the following changes in my ability at school as a result of injuries sustained in this collision: Mobility / Stability Problems Climbing Kneeling Lifting Walking For Long Periods Dexterity Problems Finger Movements Wrist Movements Postural Difficulties Problems With Tinnitus Or Ringing Of The Ears Standing For Long Periods Problems With Anxiety / Depression Problems With Vertigo Or Spinning Sensations Stooping Dizziness Sensation Of Whirling Motion Sensation Of Irregular Motion Giddiness Sitting For Long Periods Pain Where is the pain?Problems with reduced concentration: Can't Concentrate Can't think properly Making MistakesCheck any symptoms you have: Intolerance To Alcohol Impaired Comprehension Loss Of Libido Concussion Collision Extreme Thirst Ringing In Ears Bumping Into Objects In View Hearing Loss Anxiety Flash Back To Accidents Unusual Behavior Thoughts Of Death / Suicide Black Outs With Neck Movements "Graying Out" Of Vision Loss Of Bladder Control Jaw Pain Dizziness Short Term Memory Loss "Black Outs" Writing Problems Irritability Emotional Difficulties Sensitvity To Light Intolerance To Heat Missing Periods Of Time Nausea Fatigue Noise Intolerance Loss Of Balance Vertigo "Spinning Sensation" Depression Intrusive Thoughts Of Action Social Withdrawal Weight Loss / Gain Dizziness With Neck Movement Blacking Out Of Vision Loss Of Bowel Control Clicking In Jaw Difficulty Concentrating Amnesia Typing Problems Sleep Disturbances Relationship Difficulties Vision Changes Intolerance To Cold Attention Impairment Speech Difficulties Vomiting Menstrual Irregularities Loss Of Coordination Increased Symptoms Change In Personality Nightmare Since Collision Hearing Impairment "Clunk" Sound With Motion Loss Of Genital Sensation Pain With ChewingMOTOR VEHICLE ACCIDENT INSURANCE INFORMATION Patient Full Name Date Of Birth Date Of Accident Your Car Insurance Company Name What State Did The Accident Occur In? Your Adjuster's Name Your Adjuster's Phone Number Did You Open A Claim With Your Insurance Company? Claim Number With Your Insurance Company Do You Have Any Attorneys? Name Of Attorneys If Yes Do You Have Personal Injury Protection Coverage On Your Policy? Were You The At Fault Driver? Secondary Insurance (General Health Insurance) Provider Phone # Subscriber ID # Group #OTHER DRIVER INFORMATION Other Drivers Full Name Other Driver's Insurance Company Other Drivers Claim Adjuster And Phone Number Other Drivers Insurance Company's Claim Department Phone # Other Drivers Claim Number