Motor Vehicle Accident Information · Pain in Buttocks Pain and needles in Legs Pain down leg Pain in hip joint Feet feel Cold Swollen Feet Numbness in Toes Numbness of Leg Knee pain

Page 1 of 4 MV-0001

Last Name: Social Security no.:

First Name: Middle: General Information Date of Accident:

Location (circle one)

Driver

Passenger Location (circle one) Front / Middle / Rear Position (circle one) Left / Middle / Right

Work from Left to Right and Circle One

Patients Vehicle

Type : Car / Van / Pickup / Truck / Bus / SUV / M. Cycle / Other: Size : Mini / Sub Comp / compact / Mid Size / Full Size Action : Stopped / Slowing / Acceleration / Cruising Speed : (MPH) Time of Accident: Day Light / Dawn / Dusk / Dark Road Condition : Dry / Damp / Wet / Snow / Ice Visibility : Good / Fair / Poor

Impact Information: Vehicle or Object (I) Enter impact Information for up to three Vehicles or Objects

(Select one) Vehicle Object

Name Object : Vehicle Type : Car / Van / Pickup / Truck / Bus / SUV / M. Cycle / Other: Size : Mini / Sub Comp / compact / Mid Size / Full Size

Damage to Veh.: Minimal / Moderate / Extensive / Totaled / Unsure

Impact Location

Impact Information: Vehicle or Object (II) (Select one) Vehicle Object



Impact Location

Impact Information: Vehicle or Object (III) (Select one) Vehicle Object



Impact Location

Motor Vehicle Accident Information

Page 2 of 4 MV-0001

During Impact Information: Seat Belt? Yes No Brakes Applied ? Yes No

Air Bag Deployed? Yes No Seat Broken ? Yes No

Seat Back position Changed? Yes No

Head Rest : (Circle one) Low / Mid / High / None

Prepare for Accident: (Circle One) Un-expected / Expected / Expected and Braced

Body Position : (Circle one) Straight / Rotated Left / Rotated Right / Unsure / Other:

Body Thrown? Yes / No

Direction of Throw :(Circle One) Backwards / Forward / Outside / Unsure / Other: (Circle One) Head Position : Straight / Rotated Left / Rotated Right / Forward / Unsure / Other:

Head Motion :

Forward Backwards / Backwards Forward / Right Left / Left Right / Unsure / Other:

Body Impact (Indicate any parts of your body that were struck during the impact)

Head Upper Back Right hand Lower Back

Left Shoulder Left Leg Mid Torso Right Foot

Left Arm Right Leg Mid Back Left Foot

Left Elbow Right Shoulder Right Knee Other :

Left hand Right Arm Left Knee

Upper Front Torso Right Elbow Lower Front Torso

After Accident Information:

Immediately After Accident:

Dizzy/dazed Upset Weak Nervous Headache Disoriented Unconscious

/Other:

Pain (Indicate if you experienced any pain immediately following the accident)

Head Left foot Right foot Left Knee

Left Hand Left Shoulder Right Shoulder Right knee

Right Arm Left Elbow Left Arm Other :

Upper Front Torso Mid Torso Right elbow

Upper Back Mid back Lower Front Torso

Left Leg Right Leg Lower Back

Numbness:

Left Hand Right Hand Left Leg Right Leg Left Upper Arm

Right Upper Arm Left Foot Right Foot Other:

Medical Information (Did you get medical care for this accident before coming to our office)

Medical Care? Yes No

Time of care Next day / At time of Accident / Later that Day / Days Later: (Specify)

Transported Drove Self / Ambulance / Other

Went To Orthopedic / Chiropractor / Neurologist / Family Doc / ER / Other:(Specify)

Admitted to Hospital? Yes No Days Spent in Hospita:

Test: X-ray Lab Work MRI CT Scan Other:(Specify)

Treatment: Ice Pack Hot Pack None Cervical Collar Medication Other:(Specify)

Page 3 of 4 MV-0001

Previous Injuries

Previous Injuries / Accidents No Yes, Specify:

Residual pain from Previous Injuries/Accidents

No Yes, Specify:

Later Symptoms (Please note any symptoms that started after the accident occurred)

Head Headache Dizziness Blurred Vision Light Headedness Loss of Vision Fainting Loss of Memory Pain in ear Double Vision Other Specify:

Neck (with Movement) Pain in Neck Forward Backward Turn Left Popping in Neck Muscle Spasms Turn Right Bend Left bend Right Other Specify:

Shoulders Pain in Shoulder joint Tension in shoulders Muscle Spasms in Shoulder Pain across shoulder Cant raise arms above [ ] Above shoulder level [ ] Over head Other Specify:

Arms and Hands

Pain in Fingers Numbness in Left Arm Hands Cold Pin & needles in hands Numbness in Right Arm Loss of Grip Strength Pin & needles in fingers Swollen joints in Fingers Other Specify:

Chest Chest pain Pain Around Ribs Shortness of Breadth Breast Pain Other Specify:

Abdomen Nervous Stomach Nausea Diarrhea Gas Constipation Other Specify:

Mid back Sharp Stabbing Mid pain back Pain From front to back Dull Ache Pain in Kidney Area Muscle Spasms Pain between shoulders Other Specify:

Lower Back

Low Back Pain Low back pain is worse when

Working Lifting Stooping Standing Sitting Bending Coughing Lying Down Muscle Spasms

Other Specify:

Hips, Legs & Feet

Pain in Buttocks Pain and needles in Legs Pain down leg Pain in hip joint Feet feel Cold Swollen Feet Numbness in Toes Numbness of Leg Knee pain Leg cramps Cramps in Feet

Other Specify:

General

Nervousness Fatigue Irritable Depressed Generally Feel Rundown Prostate Pain/Swelling Difficulty Urinating Night Urination Cramping Irregularity

Loss of Sleep : [________________________] hrs per night Loss of weight : [________________________]lbs Gain weight : [________________________] ibs Other:

Page 4 of 4 MV-0001

Insurance Information Your Auto insurance Information (PIP-Personal Injury Protection):

Insurance: ____________________________ Address: _________________________________State ______ Zip __________

Claims Adjuster: ______________________________________ Phone: ___________________________ Ext. ___________

Claim #: _____________________________________ Date of Injury: ____________________

Other Party’s Insurance:

Insurance: ____________________________ Address: __________________________________ State ______ Zip

__________

Claims Adjuster: ______________________________________ Phone: ___________________________ Ext. ___________

Claim #: _____________________________________ Date of Injury: ____________________

Has an attorney advised you in this matter? Yes No Are you being represented? Yes No

Attorney Name: _______________________________________________ Phone # ____________________________

Address/City/State/Zip: ______________________________________________________________________________

Signature: ___________________________________________ Date: _________________________

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

MH-0001

SpinaCare Chiropractic & MassageMedical History Information

Emergency Contact Name and Number:

Last Name: Mr. Mrs.

Miss Ms.

Marital status (circle one)

First Name:Middle: Single / Mar / Div / Sep /

Widow

Email: Birth date: Age: Sex:

Address: City: State:

ZIP Code: Social Security No.:Home Phone:Cell Phone :

Occupation: Employer: Employer phone:

Medical Care Information

Do You Have a Family Doctor?: No Yes, Name of Doctor:

Address: City: State: ZIP Code:

Date of last Visit: / / Date of last exam: / /

Do You Have a Family Chiropractor?: No Yes, Name of Chiropractor:

Address: City: State: ZIP Code:

Date of last Visit: / / Date of last exam: / /

Have you had surgeries in the last 5 Years: Yes No If yes, Last Surgery Date:

Reason for Surgery:

Present illness /Conditions:

AIDS Cancer Heart Problem Multiple Sclerosis Spinal Disc Disease

Allergies Cirrhosis/hepatitis High blood pressure Pacemaker Thyroid trouble Epilepsy

Anemia Diabetes HIV/ARC Prostate trouble Tuberculosis

Arthritis Dislocated joints Kidney trouble Rheumatic fever Ulcer

Asthma Diverticulitis Low Blood Pressure Scoliosis Polio

Bone fracture Hay Fever Mental/ Emotional Difficulty Sinus trouble STD’SOther:

Family History of illness:

AIDS Cancer Multiple Sclerosis Spinal Disc Disease STD’S

Allergies Bone fracture Heart Problem Low Blood Pressure Sinus trouble Ulcer

Anemia Cirrhosis/hepatitis HIV/ARC Mental/ Emotional Difficulty Epilepsy Polio

Arthritis Diabetes High blood pressure Prostate trouble Thyroid trouble Scoliosis

Asthma Dislocated joints Kidney trouble Rheumatic fever Tuberculosis Diverticulitus

Are you currently taking any prescription or non-prescription medications?

Type of Cancer: Breast

Lung

Other:

How did you hear about us (circle one)? Sign/Location Internet Doctor’s Referral Referred by a friend/family member

Page 2 of 7

Social History:

Alcohol? No YesDrinks per week?

Cigarettes? No YesPacks per day?

Caffeine? No YesDrinks per day?

Exercise? No Yes Hours per week?(circle one) Light / Moderate / Strenuous

Signature: __________________________________________ Date: ___________________

Patient’s Name: _______________________

Date: _____________

VITALS: Weight:__________ Height:__________ Blood Pressure:__________ Pulse:__________

I Am: Right Handed:_______ Left Handed:_____

HEADACHESLocation Left Right Both Center Center and to the Left Center and to the RightPain Pain Numbness Tingling BurningSeverity Mild Mild to Moderate Moderate Moderate to Severe SeverePain scale 0 No Pain10 Excruciating Pain

No Pain 0-----1-----2-----3-----4-----5-----6-----7-----8-----9-----10 Excruciating painPlease circle the number or if it is a half please put a line between the numbers

Frequency Infrequent < 25% Occasional 25% to 50% Frequent 50% to 75% Constant > 75%Specific Site of Pain Forehead Behind Eyes Back of Skull Sides of Head Temples Throughout HeadOnset? At time of Accident After Accident Unknown

Specific Date (please write)What makes it better? Lying Down Motion of Neck Medication Nothing Sitting

Standing Stretching Chiropractic TX Heat Ice Resting

Other(specify)What makes it worse? Bright Lights House Work Load Noises Neck Movement Reading

Watching TV Working Laying to Sitting Laying to Standing Sitting to Laying Sitting to Standing Standing to Laying Standing to Sitting Other(specify)

Quality of the Pain? Ache Dull Sharp Stabbing Throbbing Electric Fiery Shooting Deep Superficial

Other(specify)Radiating (traveling pain) Neck Left Ear Left Eye Left Jaw Right Ear

Right Eve Right Jaw Other (specify)

Timing Afternoon During Night Evening During Light Activities During Moderate Activities Morning ConstantOther (specify):

Page 3 of 7

Side Effects Buzzing in Ears Dizziness Loss of Balance Nausea Ringing in Ears Sensitive to Bright Visual Problems Other (specify):

PatientComments:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DoctorNotes:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

NECKLocation Left Right Both Center Center and to the Left Center and to the RightPain Pain Numbness Tingling BurningSeverity Mild Mild to Moderate Moderate Moderate to Severe SeverePain scale 0 No Pain10 Excruciating Pain


Frequency Infrequent < 25% Occasional 25% to 50% Frequent 50% to 75% Constant > 75%Onset? At time of Accident After Accident Unknown

Specific Date (please write)What makes it better? Lying Down Medication Nothing Range of Motion Sitting

Standing Stretching Chiropractic Heat Ice Resting

What makes it worse? Neck Movement Prolonged Sitting Prolonged Standing Prolonged Walking Sneezing Daily Activities Lateral Bending L Lateral Bending R Rotation Left Rotation R

Laying to Sit Laying to Standing Sitting to Laying Sit to Standing Stand to laying Quality of the Pain? Ache Dull Sharp Stabbing Throbbing

Electric Fiery Shooting Deep Superficial Other(specify)

Radiating (traveling pain) Back of Head Sides of head Left Arm Left Fingers Left forearm Left Hand Left Shoulder Left Shoulder Blade Right Arm Right Fingers Right Forearm Right Hand Right Shoulder Right Shoulder Blade


Side Effects Decreased Range of Motion Increased Sensitivity Numbness Stiffness Tightness TinglingOther (specify):


DoctorNotes:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Page 4 of 7

UPPERBACKLocation Left Right Both Center Center and to the Left Center and to the RightPain Pain Numbness Tingling BurningSeverity Mild Mild to Moderate Moderate Moderate to Severe SeverePain scale 0 No Pain10 Excruciating Pain




Standing Stretching Chiropractic TX Heat Ice Resting Laying on Left Side Laying on Right Side Leaning Left Leaning Right

Other(specify)What makes it worse? Bending Coughing House Work Prolonged Sitting Prolonged Standing

Prolonged Walking Sneezing Working Activities of Daily living Bending Left Bending to the Right Rotating Left Rotating Right Laying to sitting Laying to Standing Sitting to Laying Standing to Laying Bowel Movements Reaching Other (specify)


Other(specify)Radiating (traveling pain) Ribs Low back

Other (specify) Timing Afternoon During Night Evening During Light Activities During Moderate Activities

Morning ConstantOther (specify):

Side Effects Decreased ROM Increased Sensitivity Numbness Stiffness Tightness TinglingOther (specify):


DoctorNotes:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MID BACKLocation Left Right Both Center Center and to the Left Center and to the RightPain Pain Numbness Tingling BurningSeverity Mild Mild to Moderate Moderate Moderate to Severe SeverePain scale 0 No Pain10 Excruciating Pain



Specific Date (please write)

Page 5 of 7

What makes it better? Lying Down Medication Nothing Motion of Mid back Sitting Standing Stretching Chiropractic TX Heat Ice

Resting Laying on left side Laying on Right Side Leaning Left Leaning Right Other(specify)

What makes it worse? Bending House Work Lifting Prolonged Sitting Prolonged Standing Prolonged Walking Working Normal Daily Activities Bend to Left Bend to Right

Rotation Left Rotation Right Laying to Sitting Laying to Standing Sitting to LayingSitting to Standing Standing to Laying Standing to Sitting Bowel Movements Reaching

Other(specify)Quality of the Pain? Ache Dull Sharp Stabbing Throbbing

Electric Fiery Shooting Deep Superficial Other(specify)

Radiating (traveling pain) Left Ribs Lower Back Neck Right RibsOther (specify)


Side Effects Decreased Motion Increased Sensitivity Numbness Tightness Tingling StiffnessOther (specify):


DoctorNotes:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

LOW BACKLocation Left Right Both Center Center and to the Left Center and to the RightPain Pain Numbness Tingling BurningSeverity Mild Mild to Moderate Moderate Moderate to Severe SeverePain scale 0 No Pain10 Excruciating Pain




Standing Stretching Chiropractic TX Heat Ice Resting Putting Knees to Chest Laying on left Side Laying on Right Side Bending Left

Bending Right Other(specify)

What makes it worse? Bending Coughing Sneezing Lying Down Lifting Sitting Prolonged Standing Prolonged Walking Normal Daily Activities Bend to Left

Bend to the Right Rotation Left Rotation Right Laying to Sitting Laying to StandingSitting to Laying Sitting to Standing Standing to Layin Standing to Sit Bowel Movements Other(specify)


Other(specify)Radiating (traveling pain) Left Buttock Left Calf Left Foot Left Hip Left Toes

Left Upper Back Right Buttock Right Calf Right Foot Right HipRightToes Right Upper Back

Page 6 of 7

Other (specify)


Side Effects Increased Sensitivity Numbness Stiffness Tightness Tingling Other (specify):


DoctorNotes:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

OTHERLocation Left Right Both Center Center and to the Left Center and to the RightPain Pain Numbness Tingling BurningSeverity Mild Mild to Moderate Moderate Moderate to Severe SeverePain scale 0 No Pain10 Excruciating Pain


Frequency Infrequent < 25% Occasional 25% to 50% Frequent 50% to 75% Constant > 75%Specific Site of Pain (Please Write in)

Onset? At time of Accident After Accident Unknown Specific Date (please write)

What makes it better?(Please Write in)

What makes it worse?(Please Write in)


Other(specify)Radiating (traveling pain)(Please Write in)


Side Effects(Please Write In)

Page 7 of 7


DoctorNotes:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

OTHER COMPLAINTS (PLEASE CHECK ANY THAT APPLY):

Balance loss Fatigue Irritability Memory loss Nervousness Tension Shortness of breath Loss of Sleep Vertigo/Dizzy Constipation Diarrhea Upset Stomach Ringing in the ear Difficulty dressing yourself

OtherComplaints:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_________________________________________________Patient’s Signature

SpinaCare Chiropractic and Massage

26832 Maple Valley Hwy, Maple Valley, WA 98038 – Phone 425-432-9001-Fax 425-432-0838

Office Policy

Please read the following financial policy carefully and sign at the bottom of the page prior to treatment. If you

have any questions, we will be happy to answer them.

1. Health Insurance: We will assist you in determining your insurance benefits. However, insurance

representatives at times give incorrect information. In addition, there are hundreds of insurance carriers

and plans in place. These plans change, often yearly and in some instances more frequently. It is your

responsibility to know your plan benefits. Please understand that your medical insurance is a contract

between you and your insurance company. Services rendered are billed following insurance carrier

guidelines and in accordance with State and Federal Laws. Copays, deductibles, and coinsurance applied

by your insurance will be billed directly to you and are your responsibility. Your copayment is due at the

time services are rendered. You are ultimately responsible for payment of services rendered in this office.

2. If you do not have health insurance: You may either pay in full at time of service or make other payment

arrangements in advance. Payment plans are available. We offer a substantial discount for full payment at

time of service.

3. Divorced parents of a patient under 18: You will be solely responsible for any co-pay and or deductible as

well as any balance not covered by your insurance.

4. Motor vehicle accident: Please be advised health insurance will not cover your treatment if coverage is

available from a personal injury protection present in an auto accident policy. Health insurance will only

cover treatment if no PIP is available or PIP benefits are exhausted. If you are not covered under a PIP

auto insurance policy and have no health insurance coverage, you may pay for treatment at the time

service or we may file a medical lien and defer payment until settlement. In order for us to defer payment

until settlement, you must be represented by an attorney and sign a contractual agreement to pay for

services rendered. We do not bill third party insurance directly.

5. Appointments: In order to serve you better, we ask that you call if unable to make an appointment or if

you will be late. Your appointment time is reserved for you. When you fail to notify our office, this leaves

a time slot open that could otherwise be filled to help someone else. Please help us help others. There is a

$35 late cancellation fee for massage therapy appointments if you cancel less than 12 hours prior to your

scheduled treatment time.

6. Payments: Monthly payments are required on all unpaid balances. Payment plans are available and can

be set up on a monthly basis. There will be a 1% monthly finance charge added to all balances after 60

days. There will be a $25 charge on all returned checks.

I have read and understand Spinacare office policies and I will honor them.

_________________________________________ _________________

Signature Date

Dr. Guy Thomson, D.C. 26832 Maple Valley Hwy, Maple Valley, WA 98038 Ph: 425-432-9001 Fax: 425-432-0838

Confidential Patient Health Information Consent Form

We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. 1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI)

for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.

2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.

3. A patient's written consent need only be obtained one time for all subsequent care given the patient in this office. 4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use

of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.

5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a compliance officer has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them.

6. Patients have the right to file a formal complaint with our compliance officer about any possible violations of these policies and procedures.

7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care.

Informed Consent for Chiropractic Spinal Manipulation, Diagnostic X-Rays and Treatment, Authorization and Release I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of therapy modalities and diagnostic x-rays, on myself (or on the patient named below for whom I am legally responsible) by the licensed doctors of chiropractic of SpinaCare Chiropractic and Massage or any doctor, who now or in the future, works as a relief doctor. I have had the opportunity to discuss with my doctor the nature and purpose of chiropractic adjustments and other procedures and understand that spinal manipulation involves the doctor placing his or her hands on my spine and delivering a quick thrust or impulse to the involved area(s). I also understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment including, but not limited to: fractures, disc injuries, strokes, dislocations, sprains, soreness, and physical therapy burns. I understand and comprehend all such risks and complications. I, by my signature below, confirm and accept care and therefore consent to and agree to those treatments deemed necessary by my doctor to be in my best interest. I authorize payment of insurance benefits directly to SpinaCare Chiropractic and Massage. I understand and agree to allow this office to use my Confidential Patient Health Information forms for the purpose of treatment, payment, healthcare operations and coordination of care and authorize SpinaCare to communicate with my medical physician(s) about my condition and treatment. I understand and agree that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand and agree that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

Dr. Guy Thomson, D.C.

Confidential Patient Health Information Consent Form I understand the Federal Government has deemed it mandatory to notify my doctor of any other party or insurance company who may be responsible for reimbursement for my treatment. I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures. I have also read, or have had read to me the above informed consent, authorization and release. I have had an opportunity to ask any and all questions about its content, and by signing below, I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for future condition(s) for which I seek treatment in this office. Patient Signature: ___________________________________________________ Date: ____/____/____ Printed Name: ________________________________________________________________________

Consent to Treatment of a Minor Child: I hereby authorize the doctors of SpinaCare Chiropractic and Massage, and/or whomever they may designate as

assistants, to administer treatment as deemed necessary to ____________________________________.

Signature of Parent or Legal Guardian: ________________________________________Relationship: __________ Date: _____/______/______ Witness signature: _____________________________________________________

Documents

Motor Vehicle Accident Information · Pain in Buttocks Pain and needles in Legs Pain down leg Pain in hip joint Feet feel Cold Swollen Feet Numbness in Toes Numbness of Leg Knee pain