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 Foods

List Typical Lunch Foods

List Typical Dinner Foods

List 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
Other

IMPACT

Did your car impact another vehicle: Yes
No

Did 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
Other

At the time of impact were you:

Looking straight ahead
Looking to the left
Looking up
Looking to the right
Looking Down

Were both hands on the steering wheel:

Yes
No

If no, which hand was on the wheel:

Right
Left

Was your foot on the brake:

Yes
No

If yes, which foot was on the brake:

Right
Left

Were you:

Surprised by impact
Braced for impact

VEHICLE

Make and model of vehicle you were in:

Were you wearing a seatbelt:

Yes
No

If yes, what type:

Lap
Shoulder

Was vehicle equipped with airbags:

Yes
No

If yes, did it inflate properly:

Yes
No

Did your seat have a headrest:

Yes
No

If yes, what was the position of the headrest:

Low
Mid
High

OTHER VEHICLE

Make and model of other vehicle:
Which direction was other vehicle headed:
Speed other vehicle was traveling:

POLICE

Did the police come to the accident site:

Yes
No

Any Witnesses:

Yes
No

Police report filed:

Yes
No

Was a traffic violation issued:

Yes
No
If yes, to whom?

PATIENT CONDITION

Were you unconscious immediately after the accident:

Yes
No
If yes, how long?

Please describe how you felt immediately after the accident:

TREATMENT

Did you go to the hospital:

Yes
No

When did you go if so:

Immediately after the accident
Next Day
2 days or more after the accident

How did you get to the hospital:

Ambulance
Private Transportation

Name of hospital:
Name of doctor:
Diagnosis:
Treatment received:
X-rays taken:

SYMPTOMS/INJURIES

Have 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
No

Mark 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 BLURRED

Is 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
Recreation

Movements that are painful to perform:

Sitting
Standing
Walking
Bending
Lying Down

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE

Have you continued to do any of the following activities despite the pain caused by your collision?

WORK

Why 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
None

My 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 Mistakes

Check 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 Chewing

MOTOR 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

Part 2: Patient Intake

Please check whether you have the following symptoms now or in the past.

HAVE YOU BEEN IN A WORK RELATED INJURY?

MOTOR VEHICLE ACCIDENT

CLICK TO SKIP IF YOU ARE NOT IN FOR A CAR ACCIDENT

ACCIDENT SITE

IMPACT

VEHICLE

OTHER VEHICLE

POLICE

PATIENT CONDITION

TREATMENT

SYMPTOMS/INJURIES

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE

WORK

DOMESTIC DUTIES:

Household:

Duration of symptoms:

Studies / Educational Duties:

I have also experienced the following changes in my ability at school as a result of injuries sustained in this collision:

Problems with reduced concentration:

Check any symptoms you have:

MOTOR VEHICLE ACCIDENT INSURANCE INFORMATION

OTHER DRIVER INFORMATION

Location

Business Hours

Map