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Intake
Please complete this questionnaire. Your answers will help us determine if we can help you. If we do not sincerely believe your condition will respond satisfactory, we will not accept your case. THANK YOU
Email address *
Name
Your answer
Gender
Marital Status
other
Your answer
Age
Your answer
Date of Birth
MM
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DD
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YYYY
Social Security Number
Your answer
Home Address
Your answer
Phone Number
Your answer
Email Address
Your answer
Employers Address
Your answer
Work Number
Your answer
Occupation
Your answer
How did you hear about us?
Your answer
Contact Information
Name
Your answer
Address
Your answer
Relationship
Your answer
Phone Number
Your answer
Reason For Visit Today (check all that apply)
A. MAJOR COMPLAINTS
1. What are your major complaints?
Shoulder Pain
Shoulder Numbness
Shoulder Tingling
Arm Pain
Arm Numbness
Arm Tingling
Forearm Pain
Forearm Numbness
Forearm Tingling
Hand Pain
Hand Numbness
Hand Tingling
Buttock Pain
Buttock Numbness
Buttock Tingling
Hip Pain
Hip Numbness
Hip Tingling
Thigh Pain
Thigh Numbness
Thigh Tingling
Leg Pain
Leg Numbness
Leg Tingling
Foot Pain
Foot Numbness
Foot Tingling
2. Date problems began
Your answer
3. Describe how problems began (fall, lifting, etc)
Your answer
4. Current pain level
No pain
Unbearable pain
5. How often do you experience symptoms
6. Are your symptoms worse in the
7. Since it began is it
8. What makes symptoms better
Your answer
9. What makes symptoms worse
Your answer
10. What daily activities are being affected
Your answer
11. Prior care/treatments for current complaints
Your answer
B. REVIEW OF SYSTEMS
Are you presently suffering (or within the past 6 months suffered) from any of the following?
1. A. General
Other
Your answer
2. What are your habits?
Never
Occasionally
Moderately
Excessively
Smoking
Alcohol
Recreational Drugs
Exercise
Stress
Poor Diet
C. MEDICAL HISTORY
1. A. Have you been to a chiropractor?
B. Do you have a family physician?
C. (Women) To the best of your knowledge are you pregnant?
(Women) Are you under the regular care of an OB-GYN?
D. Have you been hospitalized in the last 5 years?
E. Are you currently taking any medications?
If yes, which of the following
Other
Your answer
2. Which of the following illness have you had?
Other
Your answer
3. Prior injury history
Other
Your answer
4. Fractures/Broken bones (location & year)
Your answer
5. Surgery (location & year)
Your answer
D. FAMILY HISTORY
Cancer
Diabetes
Heart Trouble
High Blood Pressure
Stroke
Multiple Sclerosis
Headaches
Neck Problems
Back Problems
Disc Problems
Joint Problems
Arthritis
Pinched Nerve
Osteoporosis
Scoliosis
Bad Posture
E. INSURANCE INFORMATION
Is there insurance coverage for the vehicle you where in?
Who?
Your answer
How is this person related to you?
Other?
Your answer
Name of your auto insurance carrier?
Your answer
Have you reported this injury to your insurance carrier?
Claim adjusters name:
Your answer
Claim adjusters phone number:
Your answer
Claim number:
Your answer
Were the police called to the scene?
Was either driver cited by police?
Your answer
Other driver vehicle insurance company:
Your answer
Do you have an attorney representing you?
If yes please provide attorneys name, address and phone number
Your answer
Our office will provide insurance billing services for you if you so desire as a courtesy
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. It is essential that if your insurance carrier sends you forms that need to be signed for authorization for records that you sign these documents and send the completed forms back to the carrier as soon as possible
Your signature on this document indicates that you:
1) Agree to pay for any outstanding bills incurred in this office.
2) Authorize the release of information necessary to secure the payment of benefits.
3) Authorize insurance payments to be made directly to Back In Line Health Care.
4) Authorize the use of this signature on all insurance submissions.
5) Authorize us to communicate through text/email. (Treatment related only and will NOT be shared)
I acknowledge that typing my name below will be considered as my signature since forms are submitted electronically.
Signature
Your answer
MM
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DD
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AUTOMOBILE CRASH QUESTIONNAIRE
Patient Name
Your answer
Date
MM
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DD
/
YYYY
Date of injury
MM
/
DD
/
YYYY
Time of injury
Time
:
City where crash occurred
Your answer
Street (location) where crash occurred
Your answer
Road conditions
Estimated damage to your vehicle
Your answer
Who made estimate
Your answer
Model & Make of your vehicle
Your answer
Model & Make of other vehicle
Your answer
IMPACT DETAILS
Number of vehicles
Type of impact
Other
Your answer
Your vehicle was
Other vehicle was
During/after impact vehicle
What did vehicle hit
Your answer
Indicate if any of the following body part was hit or hit by something
Head
Your answer
Face
Your answer
Shoulder
Your answer
Arm/Hand
Your answer
Front chest wall
Your answer
Side chest wall
Your answer
Abdomen
Your answer
Hip
Your answer
Leg
Your answer
Knee
Your answer
Foot
Your answer
Where you wearing a seatbelt
Drivers foot on break at impact
Driver holding steering wheel with
Was the door(s)/trunk/hood of your vehicle damaged to the point where you could not open them
Did any airbag deploy
If yes, which bag
Your answer
Did you have any bruising after the crash
If yes where
Your answer
Awareness & Body Position Descriptions (Check all that apply)
Did you have your head and/or torso turned at the time of collision
If yes how far and why
Your answer
Were you leaning forward at the time of the impact resulting in a gap between your body and seat back
If yes how far and why
Your answer
I acknowledge that typing my name below will be considered as my signature since forms are submitted electronically.
Signature
Your answer
Date
MM
/
DD
/
YYYY
FUNCTIONAL RATING INDEX
AREA OF COMPLAINT
1. Pain Intensity
No pain
Worst possible pain
2. Sleeping
Perfect sleep
Totally disturbed sleep
3. Personal Care (washing, dressing, etc.)
No pain; no restrictions
Severe pain; 100% assistance
4. Travel (driving, etc.)
No pain on long trips
Sever pain on short trips
5. Work
Can do usual work
Cannot work
6. Recreation
Can do all activities
Cannot do any activities
7. Frequency of Pain
No pain
Constant pain; 100% of the day
8. Lifting