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Heal 360 Rehab
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New Patient Form
Medical History
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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
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Heal 360 Rehab
Rivermead Post-Concussion Symptoms Questionnaire
After a head injury or accident some people experience symptoms which can cause worry or nuisance. We would like to know if you now suffer from any of the symptoms given below. As many of these symptoms occur normally, we would like you to compare yourself now with before the accident. For each one, please circle the number closest to your answer.
0 = Not experienced at all 1 = No more of a problem 2 = A mild problem 3 = A moderate problem 4 = A severe problem
Compared with before the accident, do you now (i.e., over the last 24 hours) suffer from:
Headaches
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Feelings of Dizziness
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Nausea and/or Vomiting
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Noise Sensitivity, easily upset by loud noise
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Sleep Disturbance
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Fatigue, tiring more easily
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Being Irritable, easily angered
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Feeling Depressed or Tearful
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Feeling Frustrated or Impatient
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Forgetfulness, poor memory
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Poor Concentration
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Taking Longer to Think
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Blurred Vision
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Light Sensitivity
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Easily upset by bright light
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Double Vision
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Restlessness
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Are you experiencing any other difficulties?
Other difficulty 1 (please describe)
Severity (other difficulty 1)
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
Other difficulty 2 (please describe)
Severity (other difficulty 2)
0 - Not experienced at all
1 - No more of a problem
2 - A mild problem
3 - A moderate problem
4 - A severe problem
*King. N.. Crawford, S., Wenden, F., Moss, N., and Wade, D. (1995) J. Neurology 242: 587-592
Please do not submit any Protected Health Information (PHI).
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