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Heal 360 Rehab
About
Services
StemWave Therapy
Forms
New Patient Form
Medical History
consent to release
Acknowledgement of receipt of HIPPA Notice of Privacy Practices
Request for Confidential Communication or your Protected Health Information
Financial Responsibility Agreement
Contractual Lien
Informed Consent to Chiropractic Treatment
Duties Performed Under Duress at Work and Home
Accident Questionnaire
Post-Concussion Symptoms Questionnaire
New Patient Form
Medical History
consent to release
Acknowledgement of receipt of HIPPA Notice of Privacy Practices
Request for Confidential Communication or your Protected Health Information
Financial Responsibility Agreement
Contractual Lien
Informed Consent to Chiropractic Treatment
Duties Performed Under Duress at Work and Home
Accident Questionnaire
Post-Concussion Symptoms Questionnaire
Schedule An Appointment
Heal 360 Rehab
Accident Questionnaire
Describe Your Vehicle
1. Vehicle Type
Sports Car
Coupe
Sedan
Sports utility Vehicle
Station Wagon
Pick-up truck
Bus
Other
2. Vehicle Size
Compact
Mid-Sized
Full-Sized
Describe the Accident
3. Date of Accident
Month
Month
Day
Year
4. Actions of patient's vehicle
Crossing an intersection
stopped at an intersection
stopped for an pedestrian
stopped for traffic
traveling at posted speed limit
traveling faster than the posted speed limit
turning
5. How was the patient's vehicle hit
hit head-on
was hit on the left front
was hit on the right front
was hit on the left rear
was hot on the right rear
was rear-ended
other
6. Damage to patient's vehicle
Complete
extensive
minimal
moderate
7. Describe the second vehicle
compact
full size
mid-size
semi trailler
pick-up truck
8. Damage to the other vehicle
complete
extensive
minimal
moderate
9. Weather Conditions
Clear
Cloudy
Drizzing
Foggy
Rainy
Snowy
Stormy
Sunny
10. Road Conditions
Damp
Dry
Dry with icy patches
Iced over
Snowed over
Wer
Describe the Moment of Impact
11. Body position at the time of impact
Learning forward
Slouched down in seat
Straight
Turned to the left
Turn to the right
12. Direction body was thrown
Backward then forward
Forward then backward
to the left
to the right
about the vehicle
outside the vehicle
under the vehicle
13. Head position at impact
Straight
Tilted forward
Turn to the left
Turn to the right
14. Direction head was thrown
Backward then forward
Forward then backward
side to side
15. Type of restraint
Lap belt
Shoulder belt
Shoulder lap belt
16. Place patient was seated in the vehicle
Driver
Front Passenger
Back Passenger driver side
Back passenger right side
Back Passenger middle
Other
17. Did Airbags deploy
Yes
No
18. Were you seen at a Medical Facility following your accident
Yes
No
If yes, name and address of the facility
Patient Signature
*
Symptoms
Date of Incident
Month
Month
Day
Year
CHECK ALL YOU COMPLAINTS
3. Do you have lacerations, cuts or bruising?
Head or Face
Neck
Seat belt bruising
Cuts or bruising on your chest
Cuts or bruising on arms
Cuts or bruising on legs
Other
If other, please describe (lacerations, cuts or bruising)
4. Head Injuries (now or at the time of the accident)
Were you knocked out or unconscious
Headaches
Face pain
Pupils different sizes
Dizziness
Difficulty walking
Balance problems
Room spins
Disoriented Confusio
Day dreaming
Attention problems
Hearing problems
Change in sense of smell or taste
Difficulty speaking
Memory problems
Very tired or fatigued
Appetite change
Sleep difficulties
Visual Disturbances, blurry or double vision
Flashbacks to accident
Problems to read or write
Problems adding or subtracting
Problems learning new things
Problems understanding
Problems remembering numbers
Difficulty Concentrating
Difficulty remembering things
Difficulty making decisions
Change in Sexual Functioning
Nausea / Vomiting
Change of personality
Wanting to be alone
Mood swings
Sadness
Agitation
Anger
Helplessness
Reduce confidence
Apathy
Irritability
Sleepiness
Frustration
Impatience
Other head related issues
5. Jaw Problems
Jaw pain
Clicking
Pain while chewing
Pain while talking
Pain while yawning
Pain while moving jaw from side to side
6. Neck Injuries
Neck pain
Neck pain, numbness, tingling, weakness that radiates or goes down to RIGHT shoulder, arm, forearm or hand
Neck pain, numbness, tingling, weakness that radiates or goes down to LEFT shoulder, arm, forearm or hand
Neck pain, numbness, tingling, weakness that radiates or goes down to RIGHT UPPER BACK
Neck pain, numbness, tingling, weakness that radiates or goes down to LEFT UPPER BACK
Neck pain that causes headaches
Neck spasms or shoulder spasms
Popping, clicking or clunking sound with neck movement
7. Shoulder Injuries
Shoulder pain (left or right)
Shoulder pain with movement (left or both)
Shoulder spasms (left or both)
Sharp shoulder pain (right)
Dull shoulder pain
Achy shoulder pain
Pins and needles shoulder pain
Shoulder pain that radiates or shoots pain into arm
Other
If other, please describe (shoulder)
8. Upper Arm Pain - which side?
Right
Both
8. Upper Arm Pain - pain quality
Dull
Ache
Sharp
Stabbing
Other
If other, please describe (upper arm pain)
9. Elbow Pain - which side?
Right
Left
Both
9. Elbow Pain - pain quality
Dull
Ache
Sharp
Stabbing
Other
If other, please describe (elbow pain)
10. Forearm - which side?
Right
Left
Both
10. Forearm - pain quality
Dull
Ache
Sharp
Stabbing
Other
If other, please describe (forearm)
11. Wrist Pain - which side?
Right
Left
Both
11. Wrist Pain - pain quality
Dull
Ache
Sharp
Stabbing
Other
If other, please describe (wrist pain)
12. Hand Pain - which side?
Right
Left
Both
12. Hand Pain - pain quality
Dull
Ache
Sharp
Stabbing
Other
If other, please describe (hand pain)
13. Mid Back Pain or Upper Back Pain
Upper or mid back pain
Upper back pain, numbness, tingling, weakness that radiates or goes down to RIGHT shoulder, arm, forearm or hand
Upper back pain, numbness, tingling, weakness that radiates or goes down to LEFT shoulder, arm, forearm or hand
Upper or mid back spasms
14. Low Back Pain
Low back pain
Low back pain, numbness, tingling, weakness that radiates or goes down to RIGHT buttock, thigh, leg or foot
Low back pain, numbness, tingling, weakness that radiates or goes down to LEFT buttock, thigh, leg or foot
Low back spasms
15. Pelvic or Sacral Pain
Pelvic pain, numbness, tingling, weakness that radiates or goes down to RIGHT buttock, thigh, leg or foot
Pelvic pain, numbness, tingling, weakness that radiates or goes down to LEFT buttock, thigh, leg or foot
Sacral pain (tail bone)
Coccygeal or coccyx (tail bone) pain
16. Hip Pain - which side?
Right
Left
Both
16. Hip Pain - details
Hip pain
Hip pain, numbness, tingling, weakness that radiates or goes down to buttock, thigh, leg or foot
17. Upper Leg Pain - which side?
Right
Left
Both
17. Upper Leg Pain - details
Upper leg pain that radiates to knee
Upper leg spasms
18. Knee Pain - which side?
Right
Left
Both
18. Knee Pain - details
Knee pain that radiates to calf
Knee pain that radiates to calf and ankle
Knee pain that radiates to calf, ankle and foot
19. Ankle Pain - which side?
Right
Left
19. Ankle Pain - details
Ankle pain that radiates to foot
Ankle and foot pain
20. Foot Pain - which side?
Right
Left
Both
21. Chest Pain
Yes
No
Describe your chest pain (if applicable)
22. Stomach Pain
Yes
No
Describe your stomach pain (if applicable)
23. Other symptoms (please describe)
Please do not submit any Protected Health Information (PHI).
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