New Auto Patients Form PATIENT INFORMATIONDate MM slash DD slash YYYY SS/HIC/Patient ID # Patient Name Last name Middle Initial First Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Email Sex Male Female Age Birthdate Marital Status Married Separated Widowed Divorced Single Minor Partnered How many years? Occupation Patient Employer/School Employer/School Address Employer/School PhoneSpouse's Name Birthdate SS# Spouse's Employer Whom may we thank for referring you? INSURANCEWho is responsible for this account? Relationship to Patient? Insurance Co. Group # Is patient covered by additional insurance? Yes No Subscriber's Name Birthdate SS# Relationship to Patient Insurance Co. Group # PHONE NUMBERSHome PhoneCell PhoneBest time and place to reach you IN CASE OF EMERGENCY, CONTACTName Relationship Home PhoneWork PhoneACCIDENT INFORMATIONIs this condition due to an accident? Yes No Date of accident MM slash DD slash YYYY Type of accident Auto Work Home Other To whom have you made a report of your accident? Auto Insurance Employer Worker's Compensation Other Attorney Name (if applicable) PATIENT CONDITIONReason for visit When did your symptoms appear? Is this condition getting progressively worse? Yes No Unknown Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) Type of pain Sharp Burning Dull Tingling Throbbing Cramps Numbness Stiffness Aching Swelling Shooting 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 Activities or movements that are painful to perform Sitting Standing Walking Bending Lying Down HEALTH HISTORYWhat treatment have you already received for your condition? Medications Surgery Physical Therapy Chiropractic Services None Other Please explain Name and addres of other doctor(s) who have treated you for your condition Date of last physical exam MM slash DD slash YYYY Spinal Exam MM slash DD slash YYYY Dental X-Ray MM slash DD slash YYYY Spinal X-Ray MM slash DD slash YYYY Chest X-Ray MM slash DD slash YYYY MRI, CT-Scan, Bone Scan MM slash DD slash YYYY Blood Test MM slash DD slash YYYY Urine Test MM slash DD slash YYYY AIDS/HIV Yes No Alcoholism Yes No Allergy Shots Yes No Anemia Yes No Anorexia Yes No Appendicitis Yes No Arthritis Yes No Asthma Yes No Bleeding Disorders Yes No Breast Lump Yes No Bronchitis Yes No Bulimia Yes No Cancer Yes No Cataracts Yes No Chemical Dependency Yes No Chicken Pox Yes No Diabetes Yes No Emphysema Yes No Epilepsy Yes No Fractures Yes No Glaucoma Yes No Goiter Yes No Gonorrhea Yes No Gout Yes No Heart Disease Yes No Hepatitis Yes No Hernia Yes No Herniated Disk Yes No Herpes Yes No High Blood Pressure Yes No High Cholesterol Yes No Kidney Disease Yes No Liver Disease Yes No Measles Yes No Migraine Headaches Yes No Miscarriage Yes No Mononucleosis Yes No Multiple Sclerosis Yes No Mumps Yes No Osteoporosis Yes No Pacemaker Yes No Parkinson's Disease Yes No Pinched Nerve Yes No Pneumonia Yes No Polio Yes No Prostate Problem Yes No Prosthesis Yes No Psychiatric Care Yes No Rheumatoid Arthritis Yes No Rheumatic Fever Yes No Scarlet Fever Yes No Sexually Transmitted Disease Yes No Stroke Yes No Suicide Attempt Yes No Thyroid Problems Yes No Tonsilitis Yes No Tuberculosis Yes No Tumors, Growths Yes No Typhoid Fever Yes No Ulcers Yes No Vaginal Infections Yes No Whooping Cough Yes No Exercise None Moderate Daily Heavy Work Activity Sitting Standing Light Labor Heavy Labor Habits Smoking Alcohol Coffee/Caffeine Drinks High Stress Level Packs/Day Drinks/Week Cups/Day Reason Are you pregnant? Yes No Due Date MM slash DD slash YYYY Injuries/Surgeries you have had Falls Head Injuries Broken Bones Dislocations Surgeries Description of Fall Date MM slash DD slash YYYY Description of Head Injury Date MM slash DD slash YYYY Description of Broken Bones Date MM slash DD slash YYYY Description of Dislocations Date MM slash DD slash YYYY Description of Surgeries Date MM slash DD slash YYYY Medications Pharmacy Name Pharmacy PhoneAllergies Vitamins/Herbs/Minerals PATIENT INFORMATIONToday's Date MM slash DD slash YYYY Patient Name Date of Accident MM slash DD slash YYYY Time of Accident A.M. P.M. Please describe the accident in your own words:Were you the Driver Rear Passenger Front Passenger Pedestrian How many people were in the accident vehicle? ACCIDENT SITERoad/Street Name City/State Nearest intersection with road/street Driving Conditions Dry Wet Icy Other Please describe Which direction were you headed? Speed you were traveling? IMPACTDid your car impact another vehicle? Yes No Did your car impact a structure? Yes No Please explain Did any part of your body strike anything in the vehicle? Yes No Please explain At the time of impact were you: Looking straight ahead Looking to the left Looking to the right Looking up Looking down Were both your hands on the steering wheel? Yes No Which hand was on the wheel? Right Left Was your foot on the brake? Yes No Which foot was on the brake? Right Left Were you: Surprised by impact Braced for impact OTHER VEHICLEMake and model of other vehicle: Which direction was the other vehicle headed? Speed the other vehicle was traveling: POLICEDid the police come to the accident site? Yes No Were there any witnesses? Yes No Was a police report filed? Yes No Was a traffic violation issued? Yes No To whom? PATIENT CONDITIONWere you unconscious immediately after the accident? Yes No For how long? Please describe how you felt immediately after the accident:TREATMENTDid you go to the hospital? Yes No When did you go? Immediately after 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/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 No If you have had any of the following symptoms since your injury, please check: 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 stiffness Shortness of breath Sleep difficulty Stomach upset Tension Vision blurred Is this condition getting progressively worse? Yes No Unknown Rate the severity of your pain on a scale from 1(least pain) to 10 (severe 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 you: Work Sleep Daily Routine Recreation Activities or movements that are painful to perform: Sitting Bending Standing Lying Down Walking Δ
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