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 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 (III) (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 Motor Vehicle Accident Information
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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
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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
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 __________
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
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
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%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
Timing Afternoon During Night Evening During Light Activities During Moderate Activities Morning ConstantOther (specify):
Side Effects Decreased Range of Motion Increased Sensitivity Numbness Stiffness Tightness TinglingOther (specify):
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
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%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 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)
Quality of the Pain? Ache Dull Sharp Stabbing Throbbing Electric Fiery Shooting Deep Superficial
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):
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
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%Onset? At time of Accident After Accident Unknown
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)
Timing Afternoon During Night Evening During Light Activities During Moderate Activities Morning ConstantOther (specify):
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
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%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 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)
Quality of the Pain? Ache Dull Sharp Stabbing Throbbing Electric Fiery Shooting Deep Superficial
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)
Timing Afternoon During Night Evening During Light Activities During Moderate Activities Morning ConstantOther (specify):
Side Effects Increased Sensitivity Numbness Stiffness Tightness Tingling Other (specify):
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
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 (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)
Quality of the Pain? Ache Dull Sharp Stabbing Throbbing Electric Fiery Shooting Deep Superficial
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
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: _____________________________________________________