PERSONAL INJURY INTRODUCTION FORM - Chiropractic Lake …chiropracticlakeoswego.com/wp-content/uploads/2013/09… · Web viewPERSONAL INJURY INTRODUCTION FORM. PATIENT INFORMATION

Colling Chiropractic, PCKevin Colling D.C., FAFS / 470 6th St. Ste. C – Lake Oswego, OR 97034 – (503) 505-9806

PERSONAL INJURY INTRODUCTION FORMPATIENT INFORMATION

Today’s Date: ________________________

Last Name: MI: First Name:Home Address: City: State: Zip:Date Birth: Age: Email:Height: Weight: Drivers License No:Employer’s Name: Marital Status (Circle): Single, Married, Divorced, Widowed

Occupation: Name of Family Physician:

¨ YES, ¨ NO I authorize the following telephone numbers: ¨ YES, ¨ NO I authorize the use of my name/address

Home: ______________________Work ___________________________

Cell: _______________________ Pager: ___________________________

Indicate if you have a preferred mailing address: _____________________

________________________________________

Signature: _________________________Date:______________________

Expiration Date/Event for Authorization: ¨ No expiration date¨When I have discontinued treatment and all bills have been paid.¨ Date:

Our office needs to leave messages, return telephone calls, and send office mail to your home address as part of our normal practice. Federal/State HIPAA patient privacy laws allow you to restrict doctor/staff communication with you or to contact you through alternative means. Please list telephone numbers that are acceptable for our office to call. Your agreement will allow our office to use your name and the indicated mailing address for sending reminders about scheduled appointments, re-activation letters, sending birthday/holiday cards, office newsletters, or providing information about other health related matters that may be of interest to you, billing statements/questions, status of your account, and other office related matters. We will use your home address, noted above, unless you indicate a preferred address. You may indicate a preferred mailing address by indicating so on this form. This authorization may be revoked by you at any time, by advising our office (Privacy Officer) of this revocation in writing. If you choose not to sign this authorization, this will not have any adverse effect on your treatment, eligibility for benefits, enrollment, or payment.

AUTOMOBILE INSURANCE INFORMATIONDo you or someone else have insurance coverage for the vehicle you were in?

¨ I have, ¨ Someone else has coverage. Indicate the name of the person that the policy is under:

How is this person related to you? ¨ Self, ¨ Parent, ¨ Friend, ¨ OtherName of your Automobile Insurance Carrier:

Address of your Automobile Insurance Carrier:

Claim Adjusters Name/Telephone Number: Name: Telephone (area code):

Claim Number:

Do you have an Insurance Deductible? ¨ Yes, ¨ No Deductible is: $Do you know your Policy Limits for medical bills? ¨ Yes, ¨ No Limit is: $Have you reported this injury to your insurance carrier? ¨ Yes, ¨ No

¨ Yes, ¨ No. Do you have an attorney representing you? If yes, indicate name, address and telephone of your retained attorney:

Attorney Name: _________________________________Address: _______________________________________Telephone:

Remember that you are ultimately responsible for any charges incurred in this office. It is your responsibility to pay any deductible amount, co-insurance, and or any other balances not paid by your insurance carrier.

Patient Signature Date I am ultimately responsible for all charges that are incurred at the doctor’s office. I agree to pay for any outstanding bills incurred in this office, as well as paying for co-insurance or deductibles.

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Form 4000

GENERAL HEALTH HISTORY

Check only those conditions that apply to you and indicate if you have had in the past or presently have.YES GENERAL QUESTIONS PAST PRESENT¨ History of poor healing or told that you have a healing disorder? ¨ ¨¨ Smoke cigarettes or use tobacco products? ¨ ¨¨ Diabetes, hypoglycemia, thyroid, kidney, liver disease, or other endocrine disorder? ¨ ¨¨ Heart attack, heart disease or have a heart pacemaker or neck or chest shunt? ¨ ¨¨ History of any disease such as AIDS, Tuberculosis, Meningitis, etc.? ¨ ¨¨ Do you have difficulties or intolerance to heat packs or ice packs on your skin? ¨ ¨¨ Do you have problems with dizziness, blacking out, balance, fainting, or tripping? ¨ ¨¨ Epilepsy-Seizure-Convulsion history or any other neurological disease? ¨ ¨¨ History of multiple sclerosis, lupus, psoriasis, paralysis, or disease affecting nerves? ¨ ¨¨ Cancer history or cancer treatment of any type? ¨ ¨¨ Stroke history (Indicate any suspected strokes or transient ischemic attacks)? ¨ ¨¨ Told that you have scoliosis, spondylolisthesis, spina bifida, or fused vertebrae? ¨ ¨¨ Told that you have a bulging/herniated disc or disc degeneration in the spine? ¨ ¨¨ Have you ever been hospitalized? Why/When: ¨ ¨¨ Blood clots, bleeding or vascular disorder, or told you have an abdominal aneurysm? ¨ ¨¨ Hypertension or high blood pressure? If yes, name of MD seeing: ¨ ¨¨ Told you have weak bones, osteoporosis, osteopenia, or ankylosing spondylitis? ¨ ¨¨ Told you have arthritis, degeneration, or rheumatoid arthritis in your spine or joints? ¨ ¨¨ Do you have any type of chest or breast implants presently (males & females)? N/A ¨¨ Women only: Check box to left if there any chance that you are currently pregnant

PRIOR INJURY AND/OR PREVIOUS PAIN (¨ I have never had any injuries or pain) If yes, check below:¨ Work Injury ¨ Fall ¨ Sports Injury ¨ Lifting Injury ¨ Car Accident¨ Motorcycle Injury ¨ Head Injury ¨ Pedestrian Injury ¨ Military Injury ¨ Other Injury¨ Headaches ¨ Neck Pain ¨ Middle Back Pain ¨ Low Back Pain ¨ Shoulder Pain¨ arm numb/tingling ¨ Arm Pain ¨ Leg Pain/Tingling ¨ Other Pain:

FRACTURES/BROKEN BONES HISTORY(¨ I have never had any broken bones). If you have broken/fractured any bones, indicate where and when below:

Region Year Region Year¨ Spinal Vertebra ¨ Skull¨ Collar bone (clavicle) ¨ Rib(s) or sternum chest bone¨ Arm or hand bones ¨ Leg or foot bones¨ Pelvis or hip bones ¨ Other: List

PREVIOUS SURGERIES(¨ I have never had any surgical procedure). If you have had any previous surgery, indicate type and when:

Surgery Year Surgery Year¨ Spine Surgery (neck, back, or pelvis) ¨ Abdominal/chest Surgery or Appendix¨ Disc surgery in neck or back ¨ Gallbladder/Liver/Stomach/Kidney ¨ Heart ¨ Cancer (any type)¨ Head/Brain/Spinal Cord/Nerve ¨ Hernia (inguinal or hiatal)¨ Shoulder/Arm/Hip/Leg ¨ Other

Have you ever been to a Chiropractor before for any condition?¨ No, ¨ Yes If yes, Chiropractor’s Name : ____________________________________________________ Year:____________ Describe the problem(s) you had when previously seen by a Chiropractor:

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Form 1010

GENERAL HEALTH HISTORY (Page 2)

LIST ALL SYMPTOM REGIONS AND HOW LONG YOU HAVE HAD THEM

CHECK ALL SYMPTOM AREAS HOW LONG CHECK ALL SYMPTOM AREAS HOW LONG¨ Headaches/Migraines ¨ Upper Back Pain, Soreness, or Stiffness¨ Neck Pain, Soreness, or Stiffness ¨ Hip Pain¨ Low Back Pain, Soreness, Stiffness ¨ Leg or Foot Pain, Numbness, or Tingling¨ Arm/Hand Pain, Numbness, or Tingling ¨ Other:

Did your current symptoms come on? ¨ Suddenly, ¨ Gradually

SYMPTOM/PAIN DESCRIPTIONPlease circle any word or all words below that best describes how your symptoms currently feel to you.Pain Pinching Spreading Vicious UnbearableAche Pricking Shooting Sickening SorenessCutting Tingling Stabbing Miserable Pins and NeedlesTearing Gnawing Dull Troublesome RadiatingCrushing Nagging Bony Pressing WeaknessPulling Boring Terrifying Deep pain Falls asleepIrritating Burning-Hot Dreadful Superficial pain SuffocatingAnnoying Drill like Fearful Stinging PunishingStiff or tight Heavy Unhappy Throbbing CrawlingExhausting Numbness Torturing Sharp Tender

¨ No, ¨ Yes Do you have any problems laying face down on an examination table? If yes, why: ___________________

ARE YOU TAKING ANY MEDICATIONS PRESENTLY?¨ I am not taking any medications currently. Check any of the following that you are taking currently.¨ Muscle Relaxants ¨ Blood pressure/Stroke prevention medications ¨ Cortisone injections¨ Pain/Anti-inflammatory meds ¨ Osteoporosis (bone strengthening) medications ¨ Other:

WHEN IS YOUR PAIN WORSE & WHAT ACTIVITIES INCREASE YOUR PAIN?¨ Morning is when pain is worse ¨ Bending your back increases pain ¨ Walking increases pain¨ Afternoon/evening pain worse ¨ Lying down flat increases pain ¨ Standing increases pain¨ During sleep hours pain worse ¨ Sitting increases pain ¨ Exercise/Stretching increases pain¨ Standing up from sitting ¨ Poor posture increases pain ¨ Other:

WHAT ACTIVITIES LESSEN YOUR PAIN?¨ Walking ¨ Being flat on your back ¨ Exercise/Stretching¨ Sitting ¨ Standing ¨ Other:

DO YOU EXERCISE?¨ I do no regular exercise ¨ I exercise 1-2 times a week ¨ I exercise 3-5 times a week¨ I stretch regularly ¨ I do weight lifting at gym/home ¨ I do cardiovascular work outs¨ I am willing to do exercise ¨ I am not willing to do exercises ¨ I do regular sports activities

HAS YOUR PAIN BEEN ASSOCIATED WITH ANY OF THE FOLLOWING?¨ Excessive fatigue-malaise ¨ Bowel or bladder disorders ¨ Night pain or night time sweats¨ Weight loss ¨ Ovarian pain ¨ Abdominal pain

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¨ Low grade fever ¨ Kidney pain/painful urination ¨ Balance problems

SYMPTOM QUESTIONNAIRE (Page 3)Please answer the following sections that apply to you. If some of the questions are unclear to you, skip ahead to the next question. Your doctor will be going over this questionnaire with you during your consultation, and you can clarify your answers at that time.

NECK REGION YES NO¨ ¨ Does neck and head movement cause your neck pain to intensify? ¨ ¨ Do you get dizzy when you look up or twist your head? If yes, how often:¨ ¨ Do you black out or lose your balance when you look up or twist your head? If yes, how often:¨ ¨ Do you have to support your head with your hand or grasp your mouth or hair to be able to lift your

head up when you are lying down and attempting to sit up? If your difficulty/inability to lift your head without support is injury related, indicate how soon this occurred after injury? ( __________min/hrs)

¨ ¨ Do you feel your neck pain sends pain downwards between your shoulders?¨ ¨ Do you feel your neck pain sending pain downwards to the front of your chest?¨ ¨ Have you noticed your head leaning or tilting to one side recently?¨ ¨ Have you ever been diagnosed as having a disc bulge or disc herniation in your neck?

ARM, HAND, OR FINGER REGIONYES NO¨ ¨ Do you have pain, numbness, or tingling in your shoulder, elbow, forearm, or hand? Circle areas¨ ¨ Do you have pain, numbness, or tingling in your fingers? If Yes, circle finger(s) that are involved:

Thumb, Index finger, Middle finger, Ring finger, Little finger ¨ ¨ Do you get increased arm numbness when lying flat on your back or sleeping on your side?¨ ¨ Does changing your sitting posture increase your arm/hand symptom intensity?¨ ¨ If you sit and slouch forward for several minutes, do your arm symptoms intensify?¨ ¨ If you have arm symptoms, do they improve when you lift your arms over your head? ¨ ¨ If you have arm symptoms, do they worsen when you lift your arms over your head? ¨ ¨ If you have hand or arm pain at night, does it help to shake and massage them?¨ ¨ Do your hands feel tender when you grasp objects?¨ ¨ Do you feel weakness in your grip strength?¨ ¨ Do you drop objects from your hand?¨ ¨ Do you have difficulty writing or doing small motions with your fingers recently?¨ ¨ Do your hand(s) or wrist swell?¨ ¨ Do your hands burn?¨ ¨ Are your fingers or hands frequently cold?¨ ¨ Have you been diagnosed as having Carpal Tunnel Syndrome or Raynaud's syndrome in your past?

MIDDLE BACK AND CHEST WALL REGIONYES NO¨ ¨ Do you have pain that shoots or radiates outward along your rib cage?¨ ¨ Does your middle back or chest wall pain intensify when you take in a deep breath or cough?¨ ¨ Does your middle back or chest wall pain intensify when you twist your torso, bend, or stoop forward?¨ ¨ When you move your neck around, does your middle back pain or chest pain increase?¨ ¨ Have you been diagnosed as having angina before?¨ ¨ Do you have a tight band-like feeling sometimes around your chest?

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¨ ¨ Do you recently have any associated unusual indigestion, chest pressure, or pain down your left arm?¨ ¨ Does your middle back pain mostly bother you during sleep?

Form 1030

SYMPTOM QUESTIONNAIRE (Page 4)

LOW BACK, HIP AND LEG/FOOT REGIONCheck any of the following that intensify your low back pain and/or leg symptoms:¨ Sitting ¨ Bending forward ¨ Standing up ¨ Walking¨ Standing still ¨ Bending backward ¨ Lying on your back ¨ Putting on shoes

Check any of the following that lessen/improve your low back pain and/or leg symptoms:¨ Sitting ¨ Bending forwards ¨ Standing up ¨ Walking¨ Standing still ¨ Bending backwards ¨ Lying on your back ¨ Putting on shoes

Check all locations of any current leg pain, numbness, or tingling:¨ Hip ¨ Buttock ¨ Back of thigh ¨ Calf¨ Groin area ¨ Knee ¨ Front of thigh ¨ Foot/toes

YES NO Check all areas with a yes or no (Skip if you are unclear about question)¨ ¨ When you cough, sneeze, or bear down to have a bowel movement, does your back/leg pain get worse?¨ ¨ Do you have a consistent pattern of getting severe leg pain or cramping after walking for similar

distances that is relieved by resting or sitting down? This pain resumes after walking for same distance. ¨ ¨ Do you get leg pain or hip pain while walking that is consistently relieved by sitting down or lying down?

This pain doesn’t bother you at night or while sitting. ¨ ¨ Does either leg or foot drag on the floor when you walk?¨ ¨ Do you have a lot of leg cramps at night recently?¨ ¨ Have you recently had any urinary or bowel incontinence or had difficulty urinating?¨ ¨ Have you had abdominal pain, indigestion, colicky symptoms with your low back pain?¨ ¨ Have you observed that your low back pain is not relieved or made worse by any type of postural

change?¨ ¨ Do your feet feel cold recently? If yes, indicate which foot or if both feet:¨ ¨ Have you ever been diagnosed as having a herniated or bulging disc in your low back in the past?¨ ¨ Have you ever had an injection of Chymopapain into your discs (Spine) in your back or neck?¨ ¨ Have you recently noticed that either of your legs occasionally gives out on you when you walk?¨ ¨ Does one or both of your legs feel weak recently?¨ ¨ Have you ever been diagnosed as having a spondylolisthesis in your low back region?¨ ¨ Have you or either of your parents ever been diagnosed as having an abdominal aneurysm?¨ ¨ If you have radiating leg or foot pain did you notice your leg symptoms before the low back pain

started?¨ ¨ If you have leg pain, is your pain primarily focused in front of your thigh(s)?¨ ¨ Has your anal-rectal region been completely numb?¨ ¨ Do you have any recent prostate, ovarian, or uterine problems?¨ ¨ Have you ever had abdominal surgery, chest surgery, reconstructive surgery or other conditions in your

past where your doctor has recommended that you should be careful when twisting or lifting?¨ ¨ Other:

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SLEEPING PATTERNSYES NO¨ ¨ Do you sleep poorly at night?¨ ¨ Do you sleep on your stomach?¨ ¨ Do you consistently feel extremely tired when you wake up in the morning?

Form 1040

POST-TRAUMATIC SYMPTOM QUESTIONNAIRE

PATIENT INSTRUCTIONS: It is important for this section to be filled out in detail. Look at each symptom listed in the left column and make a single check mark or several check marks in the appropriate columns for the specific symptom which applies to you. Be certain to indicate when you had the beginning of any of the following symptoms. Leave the row blank if the symptom listed below does not apply to you.

SYMPTOMLIST

(Check all that apply to you)

BEGAN IN LESS THAN 24

HOURS AFTER INJURY

BEGAN 1 TO 7 DAYS

AFTER INJURY

YOU HAVE SYMPTOMSPRESENTLY

HAD SIMILAR SYMPTOMS WITHIN

12-MONTHSPRIOR TO THE INJURY

Headache/migraineDizzinessTinnitus (ear ringing)Blurry visionMemory problemsPoor concentrationNausea or vomitingBalance problemsLoss of coordinationSensitivity to soundSensitivity to lightFatigueLoss of smellPain/difficulty swallowingJaw pain/sorenessNeck pain/soreness/aching/stiffShoulder pain/stiffnessArm pain/tingling/numbnessWrist/hand/finger pain/numbnessWeakness in arms/legsUpper/middle back pain/sorenessChest pain or bruisingRib cage pain or bruising Abdominal-Pelvic pain or bruisingLow back pain/soreness/achingHip pain or bruisingUpper leg or thigh pain

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Leg numbness/tinglingPain radiating down leg(s)Lower leg or calf painKnee painAnkle/foot/toe painOther

MOTOR VEHICLE CRASH FORM (Page 1)

Patient Name:_____________________________________________ Date: ______________Date of crash:__________________________ Time of collision: ____________________ ¨ AM ¨ PMCity where crash occurred: ________________________________ Was the street wet or dry? ¨ Wet ¨ DryStreet (location) where crash occurred: __________________________________________________________Who owns the vehicle in which you were hit? _________________________________________________What is the estimated repair damage to your vehicle? $_____________ ¨ Unknown, ¨ Estimate not done yetHow many people were in your vehicle at the time of the crash? ___________¨ Yes, ¨ No Did the police come to the crash scene? ¨ Yes, ¨ No Did the police make a written report?¨ Yes, ¨ No Were any photographs taken of the vehicles? If yes, who took them?

DESCRIBE HOW THE CRASH HAPPENED________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

COLLISION DESCRIPTION-TYPECheck all that apply to you. Indicate which type of automobile crash you were involved in:¨ Single-vehicle crash ¨ Two-vehicle crash ¨ Three-or-more vehicles¨ Rear-end crash ¨ Side crash ¨ Rollover¨ Head-on crash ¨ Hit guard rail, tree, or object ¨ Ran off the road¨ Other (Describe):

CIRCLE YOUR SEATING POSITION (The number’s 1-9 indicate where you were seated at the time of the crash. The #1 spot is the driver. Seating numbers 7-9 are for a third row seat.

Front of Vehicle

1 2 3

4 5 6

7 8 9

Rear of Vehicle

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DESCRIBE THE VEHICLE YOU WERE IN (If not certain, check unknown): Model, Make, and Year: ¨ Unknown

DESCRIBE THE OTHER VEHICLE (If not certain, check unknown): Model, Make, and Year: ¨ Unknown

Form 4010


AT THE TIME OF IMPACT YOUR VEHICLE WAS:¨ Slowing down ¨ Gaining speed¨ Stopped ¨ Moving at a constant or steady speed

AT THE TIME OF IMPACT THE OTHER VEHICLE WAS:¨ Slowing down ¨ Gaining Speed ¨ Unknown speed¨ Stopped ¨ Moving at steady speed ¨ Other: DURING AND AFTER THE CRASH, YOUR VEHICLE:¨ Kept going straight, not hitting anything ¨ Spun around, not hitting anything¨ Kept going straight, hitting car in front ¨ Spun around, hitting another car¨ Was hit by another vehicle ¨ Spun around, hitting object/curb other than car

INDICATE IF YOUR BODY HIT SOMETHING OR WAS HIT BY ANY OF THE FOLLOWING: Please draw lines from the body regions on the left side and match to the right side.

BODY REGION OBJECT YOU HAD CONTACT WITHHead Windshield or side windowFace Steering wheel

Shoulder Side of doorArm/hand Dashboard

Front chest wall Knee bolster/glove compartmentSide chest wall Direct contact with other vehicle (hood)Hip/abdomen Frame/Pillar within vehicle near window

Knee Roof or top part of vehicleLeg Another person sitting in your vehicle

Foot Other

CHECK IF ANY OF THE FOLLOWING PARTS OF YOUR VEHICLE WERE DAMAGED IN THE COLLISION:¨ Windshield ¨ Seat bent or damaged ¨ Dash or area around knee/foot¨ Steering wheel ¨ Side or rear window broken ¨ OtherDescribe Damage:

ALL TYPES OF COLLISIONS Indicate those relevant to your case. YES NO¨ ¨ Did any of the interior front or side structures within your vehicle, such as the side door, dashboard,

steering wheel, or floorboard of your car dent inward during the crash?¨ ¨ Did the side door, dash, or interior of your vehicle touch or hit your body during the crash?¨ ¨ Did you strike or did any objects or animals within your vehicle hit you during the crash?

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¨ ¨ Was the door(s) of your vehicle damaged to a point where you could not open the door?¨ ¨ Did an airbag deploy in your vehicle during the crash? If yes, circle (side airbag/front airbag)¨ ¨ Did you have any cuts, bruises, or abrasions from the airbag deploying?¨ ¨ Did your seatbelt system require repairs after the crash?¨ ¨ Was the seat that your were sitting in damaged or bent during the crash?¨ ¨ If a side impact, did the front of the other vehicle strike the door next to where you were sitting?

Form 4010


SEATBELT USAGE AND STEERING WHEEL HAND PLACEMENT:YES NO¨ ¨ Were you wearing a seatbelt? If yes, does your seatbelt have a: ¨ Lap and Shoulder Strap,

¨ Automatic shoulder strap with driver needing to manually attach lap belt, ¨ Lap belt only¨ ¨ Did you have any portion of your seatbelt positioned behind your chest, back or shoulder. ¨ ¨ Did you have any cuts, bruises, or abrasions from the seatbelts?¨ ¨ Were you holding onto the steering wheel (driver only) at the time of impact?

If yes, Indicate where each hand was positioned (Use time clock face as your reference point) Left hand: ¨ Not on wheel, ¨ Yes, hand at ____ o’clock, ¨ Hand elsewhere Right hand: ¨ Not on wheel, ¨ Yes, hand at ____ o’clock, ¨ Hand elsewhere

REAR-END COLLISIONS ONLY Answer this section only if you were hit from the rear.Describe your vehicle’s head restraint system:

¨ Movable/adjustable head restraint ¨ Fixed, non-moveable head restraint¨ No headrests in my vehicle ¨ Bench seat in your vehicle without head restraint

Please indicate how your head restraint was positioned at the time of crash (if present):¨ At the top of the back of your head ¨ Midway height of the back of your head¨ Lower height of the back of your head ¨ Located at the level of your neck¨ Level of your shoulder blades

BRUISING AFTER THE CRASH?YES NO¨ ¨ Did your body have any bruising (areas that were visibly black, red, and/or blue) after the crash?

If yes, indicate where bruising was located on your body and what caused the bruising (if known):

AWARENESS AND BODY POSITION DESCRIPTIONS: Check all areas that apply to you.¨ You were unaware of the impending collision. You did not see or hear brakes prior to the impact.¨ You were aware of the impending crash and relaxed before the collision.¨ You were aware of the impending crash and braced yourself.¨ Your body, torso, and head were facing straight ahead.

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¨ You had your head and/or torso turned at the time of collision: ¨ Turned to left, ¨ Turned to rightDescribe how far you were turned/twisted and why you were turned/what were you doing?

¨ You were leaning forward at the time of impact resulting in a gap between your body and the seatback.If yes, indicate how far you were leaning and why you were leaning forward?

¨ Your torso/body were positioned normally against the seatback with no gaps due to leaning/twisting.

HOW SOON DID YOU FIRST NOTICE ANY PAIN/SORENESS AFTER THE CRASH?

__________________________________________________________________________________________INFORMED CONSENT

I hereby consent to the performance of chiropractic adjustments and other chiropractic procedures, on myself, (or on the patient named below, for whom I am legally responsible) by Kevin Colling, DC, and/or other licensed doctors of chiropractic who now or in the future provide chiropractic adjustments and other types of treatment for me. This consent includes other doctors of chiropractic that are employed by, associated with, or serve as back-up for Kevin Colling, DC, whether or not their names are listed on this form.

I understand and consent to the following procedures (checked below):Examination Adjustments

MobilizationGraston TherapyMyotherapy

Nutrition therapyTractionExercise

I have had an opportunity to discuss with Kevin Colling, DC the various types of treatment, including neck and spinal/extremity adjustments that have been proposed to me for my condition, and the purpose and objectives of these chiropractic procedures. I understand that the results from the chiropractic treatment are not guaranteed for my condition.

I have been informed about the risks and benefits of chiropractic adjustments and other chiropractic procedures, and understand that, there are some uncommon potential serious risks to chiropractic adjustments and procedures, including, but not limited to, sprains, fractures, disc injuries, dislocations, nerve injuries, and strokes specifically from neck adjustments. I understand and have had the opportunity to ask about risks and benefits the proposed treatment and of other alternative types of treatment for my condition.

I have had the opportunity to read this form understand the above statements, accept the risks mentioned, and hereby consent and agree to chiropractic treatment over the entire course of treatment for my present condition and any future conditions for which I seek treatment.

PATIENT NAME (PRINT): __________________________________DATE: ____________

X____________________________________________________________________________

SIGNATURE OF PATIENT OR RESPONSIBLE PARTY

NAME: ___________________________________ RELATIONSHIP: ____________________Indicate your name and relationship (parent/guardian/personal representative) if signing for patient (minor):-------------------------------------------------------------------------------------------------------------------

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OFFICE/WITNESS SIGNATURE: ________________________________DATE: __________

ACKNOWLEDGEMENT AND UNDERSTANDINGPlease initial each item below

1. __________ I hereby authorize Colling Chiropractic, PC to provide Chiropractic services for me.

2. __________ I authorize Colling Chiropractic, PC to bill my insurance for me.I understand and agree that regardless of insurance coverage, I am liable for any charges incurred as a result of services rendered to me by Colling Chiropractic PC.

3. __________ If this account is assigned to an attorney for collection and /or suit, the prevailing party shall be entitled to reasonable attorney’s fees and cost of collections.

4. __________ I understand that if I am 15 or more minutes late to an appointment; that appointment will be rescheduled. A $40.00 fee will be charged for the missed appointment.

5. __________ I understand that a 24 hour notice is required for appointment cancellation. If the required notice is not given you will be responsible for the $40.00 cost of the missed appointment.

6. __________ I understand that for anyone who chooses to pay in full at the time of service and Colling Chiropractic, PC does not bill insurance, a 20% discount will be given. All procedures are now itemized and billed accordingly. 1st visit ~ $120 - $350 depending on time and procedures. Follow up visits ~ $60 - $250 depending on time and procedures.

Dated ____________ day of _____________________ 20_____

Patient Signature

_____________________________________________________________________Guarantor Signature

_____________________________________________________________________Guarantor’s Relationship to Patient

AUTHORIZATION TO TREAT A MINOR

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As a parent or legal guardian I hereby authorize treatment for the following:

______________________________________ DOB ____________________Patient’s Full Name

To any chiropractic treatment deemed advisable, if a parent or legal guardian is not available when the child is brought in for treatment.This authorization will be effective as of _______________ and expires ________________

Signature ____________________________________ Witnessed By__________________________________

Patient Name:__________________ Date:________________

Please use the letters below to indicate the type and location of your symptoms right now.

A= Ache, B= Burning, N= Numbness (no sensation), P= Pins and Needles, S= Stabbing, O= Other (describe)

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Please rate your pain level between 0 and 10. 0 = No pain and 10 = Most intense pain imaginable.

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THE NECK DISABILITY INDEXPatient name: File#

Date:

Please read instructions:This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage everyday life. Please answer every section and mark in each section only the ONE box that applies to you. We realize that you may consider that two of the statements in any one section relate to you, but please just mark the box that most closely describes your problem.

SECTION 1-PAIN INTENSITY I have no pain at the moment. The pain is very mild at the moment. The pain is moderate at the moment. The pain is fairly severe at the moment. The pain is very severe at the moment. The pain is the worst imaginable at the moment.

SECTION 2-PERSONAL CARE (Washing, Dressing, etc.) I can look after myself normally, without causing extra pain. I can look after myself normally, but it causes extra pain. It is painful to look after myself and I am slow and careful. I need some help, but manage most of my personal care. I need help every day in most aspects of self-care. I do not get dressed; I wash with difficulty and stay in bed.

SECTION 3-LIFTING I can lift heavy weights without extra pain. I can lift heavy weights, but it gives extra pain. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, for example, on a table. Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned. I can lift very light weights. I cannot lift or carry anything at all.

SECTION 4-READING I can read as much as I want to, with no pain in my neck. I can read as much as I want to, with slight pain in my neck.

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SECTION 6-CONCENTRATION I can concentrate fully when I want to, with no difficulty. I can concentrate fully when I want to, with slight difficulty. I have a fair degree of difficulty in concentrating when I want to. I have a lot of difficulty in concentrating when I want to. I have a great deal of difficulty in concentrating when I want to. I cannot concentrate at all.

SECTION 7-WORK I can do as much work as I want to. I can do my usual work, but no more. I can do most of my usual work, but no more. I cannot do my usual work. I can hardly do any work at all. I can’t do any work at all.

SECTION 8-DRIVING I can drive my car without any neck pain. I can drive my car as long as I want, with slight pain in my neck. I can drive my car as long as I want, with moderate pain in myneck. I can’t drive my car as long as I want, because of moderate pain in my neck. I can hardly drive at all, because of severe pain in my neck. I can’t drive my car at all.

SECTION 9-SLEEPING I have no trouble sleeping. My sleep is slightly disturbed (less than 1 hr sleepless). My sleep is mildly disturbed (1-2 hrs sleepless). My sleep is moderately disturbed (2-3 hrs sleepless). My sleep is greatly disturbed (3-5 hrs sleepless). My sleep is completely disturbed (5-7 hrs sleepless).

SECTION 10-RECREATION I am able to engage in all my recreation activities, with no neckpain at all. I am able to engage in all my recreation activities, with someneck pain. I am able to engage in most, but not all, of my usual recreationactivities, because of pain in my neck. I am able to engage in few of my recreation activities, because of pain in my neck. I can hardly do any recreation activities, because of pain in myneck. I can’t do any recreation activities at all.


I can read as much as I want to, with moderate pain in my neck. I can’t read as much as I want, because of moderate pain in my neck. I can hardly read at all, because of severe pain in my neck. I cannot read at all.

SECTION 5-HEADACHES I have no headaches at all. I have slight headaches that come infrequently. I have moderate headaches that come infrequently. I have moderate headaches that come frequently. I have severe headaches that come frequently. I have headaches almost all the time.

BACK PAIN AND DISABILITY QUESTIONNAIRE (Revised Oswestry)

Patient name: File# Date:

This questionnaire has been designed to give your health care provider information as to how your back pain has affected your ability to manage everyday life. Please answer every section and mark in each section only the ONE box which applies to you. I realize you may consider that two of the statements in any one section relate to you, but please just mark the box which most closely describes your problem today.

SECTION 1 – PAIN INTENSITY The pain comes and goes and is very mild. The pain is mild and does not vary much. The pain comes and goes and is moderate. The pain is moderate and does not vary much. The pain comes and goes and is severe. The pain is severe and does not vary much.

SECTION 2 – PERSONAL CARE I would not have to change my way of washing or dressing in order to avoid pain. I do not normally change my way of washing and dressing even though it causes some pain. Washing and dressing increase the pain but I manage not to change my way of doing it. Washing and dressing increase the pain and I find it necessary to change my way of doing it. Because of the pain I am unable to do some washing and dressing. Because of the pain I am unable to do any washing and dressing without help.

SECTION 3 – LIFTING I can lift heavy weights without extra pain. I can lift heavy weights but it causes extra pain. Pain prevents me from lifting heavy weights off the floor. Pain prevents me from lifting heavy weights off the floor, but I manage if they are conveniently positioned (e.g. on a table). Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned.

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SECTION 6 – STANDING I can stand as long as I want without pain. I have some pain on standing but it does not increase with time. I cannot stand for longer than one hour without increasing pain. I cannot stand for longer than ½ hour without increasing pain. I cannot stand for longer than 10 minutes without increasing pain. I avoid standing because it increases the pain straight away.

SECTION 7 – SLEEPING I get no pain in bed. I get pain in bed but it does not prevent me from sleeping well. Because of pain my normal night’s sleep is reduced by less than ¼. Because of pain my normal night’s sleep is reduced by less than ½. Because of pain my normal night’s sleep is reduced by less than ¾. Pain prevents me from sleeping at all.

SECTION 8 – SOCIAL LIFE My social life is normal and gives me no pain. My social life is normal but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing, etc. Pain has restricted my social life and I do not go out very often. Pain has restricted my social life to my home. I have hardly any social life because of the pain.

SECTION 9 – TRAVELING I have no pain while traveling. I have some pain while traveling but none of my usual forms of travel make it any worse. I have extra pain while traveling but it does not compel me to seek alternate forms of travel. I have extra pain while traveling that compels me to seekalternative forms of travel. Pain restricts all forms of travel. Pain prevents all forms of travel except that done lying down.

SECTION 10 – CHANGING DEGREE OF PAIN My pain is rapidly getting better. My pain fluctuates but overall is definitely getting better. My pain seems to be getting better but improvement is slow at present. My pain is neither getting better nor worse. My pain is gradually worsening. My pain is rapidly worsening.


I can only lift very light weights at the most.

SECTION 4 – WALKING I have no pain on walking. I have some pain on walking but it does not increase with distance. I cannot walk more than 1 mile without increasing pain. I cannot walk more than ½ mile without increasing pain. I cannot walk more than ¼ mile without increasing pain. I cannot walk at all without increasing pain.

SECTION 5 – SITTING I can sit in any chair as long as I like. I can only sit in my favorite chair as long as I like. Pain prevents me from sitting more than 1 hour. Pain prevents me from sitting more than ½ hour. Pain prevents me from sitting more than 10 minutes. I avoid sitting because it increases my pain right away.

NOTICE OF DOCTOR’S PRIVACY PRACTICE (WITH EMPLOYEES-STAFF)The Colling Chiropactic,PC office, located at 470 6th St, Ste C, Lake Oswego, OR, 97034 is required by the Health Insurance Portability and Accountability Act (HIPAA) to inform all patients about the recent Federal/State standards that have been adopted to protect the privacy and confidentiality of all patients’ identifiable and protected health information (PHI). Our office has certain responsibilities to the patient that are outlined in this notice. This notice describes the various rights that patients have regarding PHI. If the patient desires a copy of this notice, our office will provide one, upon request (45 CFR Sect 164).

PATIENT RIGHTS REGARDING HEALTH-MEDICAL RECORDSAll medical records, including those that the patient, doctor(s), nurses, therapists, laboratory technicians, and staff generate, including intake forms, history, examination, diagnosis, treatment, progress notes, therapy, testing, etc., as well as any records received from other sources become the property of this facility. The patient has the right to inspect and copy his/her health records, amend or change his/her records, and request restrictions on certain aspects of his/her medical records for a period of seven years or as long as the patient’s records are maintained by this facility. If the patient has any sensitive PHI information he/she wants “restricted,” the patient may request that the PHI be “restricted” unless specifically authorized by the patient or when mandated by a legal or court order. If the patient provides sensitive information (such as psychotherapy, domestic violence, AIDS/HIV, communicable disease, elder abuse, drug-alcohol abuse, mental impairment, and etc) these require special authorization for release of records to other parties. The patient may ask for an accounting for every disclosure and use of his/her PHI to another party at any time. The patient may ask that disclosure of his/her PHI be communicated in a different manner, such as by fax instead of by postal service. Our office will not disclose any PHI without the patient’s signed and dated authorization, unless mandated by law (such as a court order), in an emergency situation, when providing treatment to the patient based on prescribed orders from another health care provider, or when compelled to do so in cases of potential harm/injury to a person, abuse, or crime as dictated by law. The patient may revoke any authorization, except in situations where actions or reliance upon have already been taken. All requests for amendments, viewing or copying records, restrictions, revocation of authorizations, or request for summary of disclosures or uses of patient records must be submitted in writing to the privacy officer. Please give our office enough time to process any requests. If requesting records, HIPAA laws allow for 30 days if records are maintained on-site and 60 days if stored off-site.

WHAT ARE OUR RESPONSIBILITIES TO THE PATIENT?Our office is required to maintain reasonable and appropriate administrative, technical, and physical safeguards to insure the integrity and confidentiality of patient’s PHI and protect against unauthorized uses or disclosures of the PHI. Our office is required to allow the patient to indicate alternative means of communication from our office, including preferred address locations for mail and alternative telephone numbers for receiving calls or for leaving messages. Any person/business who has access to, or needs disclosure of a patient’s PHI in order to perform necessary tasks, (examples include computer, technical, billing, janitorial, physician, diagnostic, laboratory, or radiology services) will be required to sign a “Business Associate” agreement that require appropriate safeguarding of PHI. Our office reserves the right to change our practices and make new provisions or disclosures. Our office will make every reasonable effort to comply with protecting the patient’s PHI and if the health information practices of our office change, the patient will be mailed a copy of such changes to the most recent address given by the patient.

HOW WILL OUR OFFICE USE YOUR PROTECTED HEALTH INFORMATION?This office has several doctors, therapists, assistants, and other personnel that work as a team to provide the patient with the best care in a coordinated effort. Your medical-health records that are generated each visit provide the basis for our office to determine your diagnosis, what treatment needs to be prescribed or modified, how you have responded to treatment, whether consultation/referral is needed, and provides the

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means for the doctors/staff to communicate relevant PHI with each other. Unless restricted by the patient, our office will use the patient’s PHI to coordinate care and to obtain information to verify and process insurance billing, provide “minimum necessity” records to those third-party payors who are responsible to pay for services given, and to obtain authorization for treatment, services, procedures, testing, and for supplies provided. The patient’s PHI will be used to help determine the condition, diagnosis, treatment, and the need for consultation, referral, testing, or coordination with other health care providers. The patient’s PHI may be used to respond to questions from insurance companies regarding the necessity of a service, test, or supplies or to verify services. Our office will use the patient’s PHI to return telephone calls, make appointment reminders, mail billing statements or updates, and for sending other office related material. For cases in which the patient has an attorney, our office needs to be able to communicate about various aspects of the patient’s case and submit reports outlining the patient’s response to treatment, diagnosis, and other relevant issues. If the patient has a friend, family member, or other person in attendance at our office, the patient must provide signed consent for any discussions that involve any PHI. If the patient’s doctor is out of the office and has another doctor covering his/her practice, the patient’s PHI is necessary for the doctor to provide treatment.

NOTE: Patients are encouraged to mail written recommendations or file complaints directly to the office address above with ATTN: PRIVACY OFFICER on envelope. If the patient believes that the health care provider has violated his/her privacy rights he/she may file complaints with the U.S. Department of Health and Human Services at 200 Independence Ave, SW, Room 509F, HHH Bldg, Washington, DC 20201. Our office will not retaliate in any manner if any complaints are made. Thank you.

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Documents

PERSONAL INJURY INTRODUCTION FORM - Chiropractic Lake …chiropracticlakeoswego.com/wp-content/uploads/2013/09… · Web viewPERSONAL INJURY INTRODUCTION FORM. PATIENT INFORMATION