~»CENTURY MASSAGE AUTOIWORK INJURY INTAKE FORM

Personal Information

Name: _______________________ Date:

Address: _ City: State: Zip: _

Phone: _ Email:

Emergency contact: Phone: Relationship:

Occupation: _________ Employer: _________ Date of Birth:

Reason for visit: Auto Accident ( Work Injury (

Date of injury/accident: Do you have a prescription/referral? Yes ( No (

Referred by: Phone Number: _

Primary Care Physician: Phone Number: _

Insurance/Attorney Information

Your Insurance Provider: Policy/Claim Number:

Contact Person/Adjustor/Case Manager: Phone Number: _

Have you retained an attorney for this incident? Yes () No (

Attorney's Name: Phone Number: _

If auto accident, were you at fault? Yes ( ) No (

If no, Insurance Company of person at fault: Claim Number: _

Phone number:

Authorization/Consent

I hereby authorize the release of medical information necessary to process my insurance claim. This may includeintake forms, chart notes, reports, correspondences, billing statements and any other information to my attorneys,health care providers and insurance case managers. I understand that I am responsible for all charges for theservices provided. In the event the insurance company denies benefits or makes a partial payment, I am responsiblefor any balance due. I understand the benefits and risks of massage and give consent for massage. I will consult mypractitioner with any questions or concerns immediately.

Signature Date _

HEALTH REPORT

Patient Name Date

Date of injury DOB _

A. Draw today's symptoms on the figure.

1. Identify CURRENTsymptomatic areas in your body by marking letters on the figures below. Use the

letters provided in the key to identify the symptoms you are feeling today.

2. Circle the area around each letter, representing the size and shape of each symptom location.

Key: P::::pain or tenderness S::::joint or musclestiffness N ::::numbnessor tingling SP::::spasmor cramping

B. Identify the intensity of your symptoms.

3. Pain Scale: Mark a line on the scale to show the amount of pain you are experiencing today.

No Pain I I Unbearable Pain

4. Activities Scale: Mark a line on the scale to show the limitations you are experiencing todayin your daily activities.

Can do anything I want I I Cannot do Anything

C. Comments

D. Signature Date

INJURY INFORMATION: AUTO ACCIDENT

Name _ Date _

_______ Birth Date Claim #Date of injury

1. Was there a police report? ( ) Yes () No

2. Please describe how the accident occurred. If you were decreasing, increasing or steady speed, head

position, if the other vehicle was moving, if your vehicle hit anything else after the initial impact, andwhat were the road conditions. _

3. Were you aware of the approaching vehicle or was the impact a surprise? ( ) Aware () Surprise

4. Did you lose consciousness? ( ) Yes () No

5. Where were you seated in the vehicle? _Were you wearing a seatbelt? ( ) Yes () No

6. Was the top of the headrest: ( ) Above your head () Below your headDoes your head touch the headrest? ( ) Yes () No

7. Did any part of your body come into contact with the vehicle? ( ) Yes () No Explain _

8. Is your vehicle equipped with an airbag? ( ) Yes ( ) No Did it activate? ( ) Yes () No

9. Describe how you felt during and immediately after the injury: _

Later that same day _The next day _The next week _

The next month _Describe any bruises, cuts, or abrasions as a result of the injury _

10. Are your symptoms ( ) getting better () getting worseWhat makes them feel better? _Worse? ~ _

} no change

11. Which work activities are affected by the injury? _Have your work responsibilities changed as a result of this injury? ( ) Yes () NoExplain _What other activities are affected by this injury? _

12. Check all of the following symptoms that you have experienced since the accident: ( ) Lossof memory( ) Lossof balance () Visual disturbances () Hearing difficulties () Difficulty breathing () Insomnia( ) Muscle spasms () Headaches () Numbness ( ) Tingling () Neck Pain () Upper back/shoulderpain () Mid-back pain ( ) Low back pain () Other _

Signature _ Date _

Name _

LOW BACK DISABILITY INDEX

DOB _ Date _

This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage ineveryday life. Please answer every section and mark in each section only ONE box which applies to you. We realize you mayconsider that two of the statements in anyone section relate to you, but please just mark the box which MOST CLOSELYdescribes your problem.

Section 1 - Pain Intensity

o I can tolerate the pain without having to use painkillers.o The pain is bad but I can manage without taking painkillers.o Painkillers give complete relief from pain.o Painkillers give moderate relief from pain.o Painkillers give very little relief from pain.o Painkillers have no effect on the pain and I do not use them.

Section 2 - Personal Care (Washing, Dressing, etc.)

o I can look after myself normally without causing extra pain.o I can look after myself normally but it causes extra pain.o It is painful to look after myself and I am slow and careful.o I need some help but manage most of my personal care.o I need help every day in most aspects of self care.o I do not get dressed, I wash with difficulty and stay in bed.

Section 3 - Lifting

o I can lift heavy weights without extra pain.o I can lift heavy weights but it gives extra pain.o Pain prevents me from lifting heavy weights off the floor, but

I can manage if they are conveniently positioned, forexample on a table.

o Pain prevents me from lifting heavy weights, but I canmanage light to medium weights if they are convenientlypositioned.

o I can lift very light weights.o I cannot lift or carry anything at all.

Section 4 - Walking

o Pain does not prevent me from walking any distance.o Pain prevents me from walking more than one mile.o Pain prevents me from walking more than one-half mile.o Pain prevents me from walking more than one-quarter mileo I can only walk using a stick or crutches.o I am in bed most of the time and have to crawl to the toilet.

Section 5 -- Sitting

o I can sit in any chair as long as I likeo I can only sit in my favorite chair as long as I likeo Pain prevents me from sitting more than one hour.o Pain prevents me from sitting more than 30 minutes.o Pain prevents me from sitting more than 10 minutes.o Pain prevents me from sitting almost all the time.

Scoring: Questions are scored on a vertical scale of 0-5. Total scoresand multiply by 2. Divide by number of sections answered multiplied by10. A score of 22% or more is considered significant activities of dailyliving disability.(Score x 2) I (___Sections x 10) = %ADL

Section 6 - Standing

o I can stand as long as I want without extra pain.o I can stand as long as I want but it gives extra pain.o Pain prevents me from standing more than 1 hour.o Pain prevents me from standing more than 30 minutes.o Pain prevents me from standing more than 10 minutes.o Pain prevents me from standing at all.

Section 7 -- Sleeping

o Pain does not prevent me from sleeping well.o I can sleep well only by using tablets.o Even when I take tablets I have less than 6 hours sleep.o Even when I take tablets I have less than 4 hours sleep.o Even when I take tablets I have less than 2 hours sleep.o Pain prevents me from sleeping at all.

Section 8 - Social Life

o My social life is normal and gives me no extra pain.o My social life is normal but increases the degree of pain.o Pain has no significant effect on my social life apart fromlimiting my more energetic interests, e.g. dancing.

o Pain has restricted my social life and I do not go out asoften.

o Pain has restricted my social life to my home.o I have no social life because of pain.

Section 9 - Traveling

o I can travel anywhere without extra pain.o I can travel anywhere but it gives me extra pain.o Pain is bad but I manage journeys over 2 hours.o Pain is bad but I manage journeys less than 1 hour.o Pain restricts me to short necessary journeys under 30

minutes.o Pain prevents me from traveling except to the doctor or

hospital.

Section 10 - Changing Degree of Pain

o My pain is rapidly getting better.o My pain fluctuates but overall is definitely getting better.o My pain seems to be getting better but improvement is slowat the present.

o My pain is neither getting better nor worse.o My pain is gradually worsening.o My pain is rapidly worsening.

Comments _

Name! _ DaB Date. _

NECK DISABILITY INDEX

This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage ineveryday life. Please answer every section and mark in each section only ONE box which applies to you. We realize you mayconsider that two of the statements in anyone section relate to you, but please just mark the box which MOST CLOSELYdescribesyour problem.

Section 1 - Pain Intensity

o I have no pain at the moment.o The pain is very mild at the moment.o The pain is moderate at the moment.o The pain is fairly severe at the moment.o The pain is very severe at the moment.o The pain is the worst imaginable at the moment.

Section 2 -- Personal Care (Washing, Dressing, etc.)

o I can look after myself normally without causing extra pain.o I can look after myself normally but it causes extra pain.o It is painful to look after myself and I am slow and careful.o I need some help but manage most of my personal care.o I need help every day in most aspects of self care.o I do not get dressed, I wash with difficulty and stay in bed.

Section 3 - Lifting

o I can lift heavy weights without extra pain.o I can lift heavy weights but it gives extra pain.o Pain prevents me from lifting heavy weights off the floor, but

I can manage if they are conveniently positioned, forexample on a table.

o Pain prevents me from lifting heavy weights, but I canmanage light to medium weights if they are convenientlypositioned.

o I can lift very light weights.o I cannot lift or carry anything at all.

Section 4 - Reading

o I can read as much as I want to with no pain in my neck.o I can read as much as I want to with slight pain in my neck.o I can read as much as I want with moderate pain.o I can't read as much as I want because of moderate pain in

my neck.o I can hardly read at all because of severe pain in my neck.o I cannot read at all.

Section 5-Headaches

o I have no headaches at all.o I have slight headaches which come infrequently.o I have slight headaches which come frequently.o I have moderate headaches which come infrequently.o I have severe headaches which come frequently.o I have headaches almost all the time.

Scoring: Questions are scored on a vertical scale of 0-5. Total scoresand multiply by 2. Divide by number of sections answered multiplied by10. A score of 22% or more is considered a significant activities of dailyliving disability.(Score_ x 2) I (_Sections x 10) = %ADL

Section 6 - Concentration

o I can concentrate fully when I want to with no difficulty.o I can concentrate fully when I want to with slight difficulty.o I have a fair degree of difficulty in concentrating when I want to.o I have a lot of difficulty in concentrating when I want to.o I have a great deal of difficulty in concentrating when I want to.o I cannot concentrate at all.

Section 7-Work

o I can do as much work as I want to.o I can only do my usual work, but no more.o I can do most of my usual work, but no more.o I cannot do my usual work.o I can hardly do any work at all.o I can't do any work at all.

Section 8 - Driving

o I drive my car without any neck pain.o I can drive my car as long as I want with slight pain in my neck.o I can drive my car as long as I want with moderate pain in myneck.

o I can't drive my car as long as I want because of moderate painin my neck.

o I can hardly drive my car at all because of severe pain in myneck.

o I can't drive my car at all.

Section 9 - Sleeping

o I have no trouble sleeping.o My sleep is slightly disturbed (less than 1 hr. sleepless).o My sleep is moderately disturbed (1-2 hrs. sleepless).o My sleep is moderately disturbed (2-3 hrs. sleepless).o My sleep is greatly disturbed (3-4 hrs. sleepless).o My sleep is completely disturbed (5-7 hrs. sleepless).

Section 10 - Recreation

o I am able to engage in all my recreation activities with no neckpain at all.

o I am able to engage in all my recreation activities, with somepain in my neck.

o I am able to engage in most, but not all of my usual recreationactivities because of pain in my neck.

o I am able to engage in a few of my usual recreation activitiesbecause of pain in my neck.

o I can hardly do any recreation activities because of pain in myneck.

o I can't do any recreation activities at all.

Commen~ ___