Formulario en Línea

Empecemos

Step 1 of 5 ( 20% )

Tu información

informacion de Empleo

Información de salud

Sintomas

Medición del dolor

INFORMACION DEL PACIENTE (*=Campos requeridos)

Primer Nombre|First Name

Segundo Nombre|Middle Name

Apellido|Last Name

Nombre Preferido|Preferred Name

Seguro Social|Social Security Number (Optional)

Licencia de Manejar /Identificación|Driver's License #/ID (Optional)

Fecha de nacimiento|Date of Birth

Edad|Age

Sexo|Gender?*
Hombre/MaleMujer/Female

Estado Civil|Status?*
Soltero/SingleCasado/MarriedSeparado/SeparatedDivorciado/DivorcedViudo/Widowed

Correo Electronico|Email

Dirección de Envio|Address

Ciudad|City

Estado|State

Código Postal|Zip

Contacto de Emergencia Nombre|Emergency Contact #1

Teléfono|Contact #1 Phone

Relacion|Relationship of Emergency Contact #1
Esposa/SpouseFamilia/FamilyAmigo/FriendOtro/Other

Contacto de Emergencia Nombre|Emergency Contact #2

Teléfono|Contact #2 Phone

Relacion|Relationship of Emergency Contact #2
Esposa/SpouseFamilia/FamilyAmigo/FriendOtro/Other

ASEGURANZA

¿Tiene seguro médico?|Do You Have Health Insurance?*
Si/YesNo

En caso afirmativo, traiga la tarjeta del seguro médico a la oficina en su primera visita.

Información de seguro de automóvil|Auto Insurance Information

Revisa todo lo que tienes|Check All That You Have
Seguro de Auto/Auto InsuranceProteccion de Lastimadura Personal/Personal Injury Protection (PPP)Motorista Sin Serugo/Uninsured MotoristMed Pay

Nombre de la Compania/Auto Insurance Policy Provider

Nombre del Asegurado/Auto Insurance Policy Number

Tel fono/Auto Insurance Phone Number

Ajustador|Adjuster's Name

Afirmar/Claim #

La responsabilidad de terceros|Third Party Liability (if applicable)

Proveedor de pólizas de seguro de automóvil externo/3rd Party Auto Insurance Policy Provider

Nombre del Asegurado/3rd Party Auto Insurance Policy Number

Tel fono|3rd Party Auto Insurance Phone Number

Ajustador|3rd Party Adjuster's Name

Si usted no tiene la información de la persona culpable con usted, por favor traiga esa información
con usted en su próxima visita. Gracias!

RECORDATORIOS DE CITA

Su salud es importante para nosotros!
Nuestra oficina enviar recordatorios de texto a su tel fono celular para recordarle las horas de su cita.
Aseg rese de haber incluido la compa ia de su telefon a celular en el espacio provisto arriba.
La informaci n de su tel fono cellular es informaci n protegida y no se compartir con nadie.

Pre-Injury Health History Questionnaire

Step 2 of 5 ( 40% )

Tu información

informacion de Empleo

Información de salud

Sintomas

Medición del dolor

Review of Symptoms

Constitutional*
FaintingLow LibidoPoor AppetiteFatigueSudden Weight GainSudden Weight LossWeaknessNone of the Above

Respiratory*
AsthmaApneaEmphysemaHay FeverShortness of BreathPneumoniaNone of the Above

Cardiovascular*
High Blood PressureLow Blood PressureHigh CholesterolPoor CirculationAnginaExcessive BleedingNone of the Above

Gastrointestinal*
Anorexia/BulimiaUlcerFood SensitivitiesHeartburnConstipationDiarrheaNone of the Above

Genitourinary*
Kidney StonesInfertilityBedwettingProstate IssuesErectile DysfunctionPMS SymptomsNone of the Above

Integumentary*
Skin CancerPsoriasisEczemaAcneHair LossRashNone of the Above

Neurological*
Blurred VisionRinging in EarsHearing LossChronic Ear InfectionLoss of SmellLoss of TasteNone of the Above

Endocrine*
Thyroid IssuesImmune DisordersHypoglycemiaFrequent InfectionSwollen GlandsLow EnergyNone of the Above

History

Mother's Family History

Mother's Age (or age at death)

State of Health*
GoodFairPoor

Cause of Death*
NaturalIllnessOtherN/A-Still Living

History of these illnesses *
CancerStrokeHeart DiseaseDiabetesAuto-ImmuneN/A

Other Illness, what was it?

Father's Family History

Father's Age (or age at death)

State of Health*
GoodFairPoor

Cause of Death*
NaturalIllnessOtherN/A-Still Living

History of these illnesses *
CancerStrokeHeart DiseaseDiabetesAuto-ImmuneN/A

Other Illness, what was it?

Social History

Alcohol Use

Coffee Use

Tobacco Use

Exercise

Pain Relievers

Soft Drinks

Water

Past Medical History

Illness*
AIDSAlcoholismAllergiesArteriosclerosisCancerChicken PoxDiabetesEpilepsyGlaucomaGoiterGoutHeart diseaseHepatitisHIV PositiveMalariaMeaslesMultiple SclerosisMumpsScarlet feverSexually transmitted diseasePolioRheumatic feverStrokeTuberculosisTyphoid feverUlcerNone

Are there any other illnesses to mention?

Any surgeries PRIOR to injury?

Surgeries* NoneAppendix removalBypass surgeryCancer relatedCosmetic surgeryEye surgeryHysterectomyPacemakerTonsillectomySpinal SurgeryJoint Surgery

Elective Surgeries?

Other Surgeries?

Medications & Allergies

Please list below all prescription, over-the-counter or natural supplements you are taking

List Medication

Are you allergic to any medications?

Allergies*
YesNo

If yes, please list

Dominant Hand

Dominant Hand*
RightLeftAmbidextrous (both)

You Are @ Step 3 Now!

Step 3 of 5 ( 60% )

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ACCIDENT INFORMATION

Select The Type of Accident You Had

Type of Accident*
Slip & FallAuto Accident

"PERSONAL INJURY or SLIP/FALL"

Report Filed*
YesNo

Describe How and Where the injury occurred:

Describe Accident

Address

City

County/State

MECHANISM OF INJURY*
FallSlipTripOther

Did You Fall:*
ForwardBackwardsLeftRight

How Far Did You Fall?

Time of Day?

Did you fall off of something or into something?*
YesNo

Please Describe

What body parts were hit/impacted

Were you able to catch yourself?*
YesNo

Please Describe how you were able to catch yourself

Did you hit your head?*
YesNo

Did you lose consciousness?*
YesNo

Upload INJURY Pictures

"MOTOR VEHICLE ACCIDENT (Patient)"

Was A Police Report Filed*
Yes (Bring Copy)No

Date of Injury

Address/Intersection

City

County/State

Was your vehicle totaled?*
YesNoUnsure

Was the Other vehicle totaled?*
YesNoUnsure

Was your vehicle Drivable?*
YesNoUnsure

Was the Other vehicle Drivable?*
YesNoUnsure

Did the accident take place at:*
Traffic-Light4-Way Stop2-Way StopParking LotHighwayOther

How many people were in your vehicle?

Describe The Accident

Motor Vehicle Information

Your Vehicle(s) was a:

Other Vehicle(s) was a

Direction of Impact:*
Rear-endedFront-end impactedT-Boned Driver-PassengerRolloverSide Impact Driver-PassengerOther

Detail Other Impact

Location of Impact:*
FrontSideRear

How Many Cars Involved?

Weather Conditions*
DryRainIceFog

Time of day the accident occured*
MorningNoonAfternoonEvening

Did your car strike anything else after impact?

How far did your car move as a result of the impact?

MECHANISM OF INJURY

Patient Name

You Were The:*
DriverFront PassengerLeft-Rear PassengerMiddle-Rear PassengerRight-Rear PassengerOther

Were you wearing your seatbelt?*
YesNo

Did your airbag deploy?*
YesNo

Were you able to brace for impact?*
YesNo

Were you facing:*
Straight AheadLeftRightUnsure

Did any part of your body hit any part of the car?*
YesNoUnsure

If yes, describe below

Upload MOTOR VEHICLE ACCIDENT Pictures

Upload INJURY Pictures

You Are @ Step 4 Now!

Step 4 of 5 ( 80% )

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Post-Injury Questionnaire

Did you go to the hospital following your accident?
YesNo

Did you use an Ambulance?
YesNo

Name of Hospital (please provide us with your discharge paperwork)

When did you go to the Hospital?
Immediately AfterA few hours afterOne day laterA few days laterCan't Remember

What Tests or Diagnostics Were Done? (select all that apply)
MRICT ScanX-RaysTests conducted Lying DownTests Conducted Standing

Describe Tests Conducted

Were you treated at the scene of the accident?
YesNo

Have you seen any other healthcare providers for this injury?
YesNo

Name of Other Clinic or Doctor

SINCE THE ACCIDENT

Self-care has consisted of: (select all that apply)
Prescription medicationOTC medicationHomeopathic remediesSurgeryAcupunctureChiropractic careIceHeatMassagePhysical TherapyRestPain Relief CreamsWearing a support/braceOther

List any Other Self-Care here

ACTIVITIES OF DAILY LIVING

How injuries sustained currently interfere with life and ability to function: (select all that apply)
SittingRising out of chairStandingWalkingLying downBending overClimbing stairsDriving a carTurning headHousehold choresLifting objectsReaching upShowering or bathingGetting dressedLove lifeSleepConcentratingExercisingOther

List any Other Activities here

Work Status

Were you employed at the time of your accident?
YesNo

List Occupation

Have you missed work because of this accident?
YesNo

If Yes, How Long?

Are you self-employed?
YesNo

If not Employed, select any that apply
StudentRetiredDisabledHomemaker

Why have you missed work?
A doctor took you off workYou took yourself off workYou had no transportation after the accidentYour boss took you off workYou were fired or lost your job as a result of this accidentOther

List any other reason you missed work:

Do you continue to work despite the pain?*
YesNo

Have you returned to work as of today?
YesNo

Are you working restricted or light duty?
YesNo

List any work restrictions:

GAP

List the amount of time between accident and treatment:

Describe the time after your accident:
I’ve been taking medication as prescribed. My pain still persists.I don’t usually run to the doctor when I first experience pain; however, I’m not better.I tried to treat myself at home; however, the pain did not go away.I was feeling okay at the scene of the accident, but the pain worsened in the days following.I wanted to wait to see if the pain would go away. I am still in pain.I was treated at a different clinic for a time, but I am not feeling better. I am here for a second opinion.Other

Add any other here:

Are any of your current injuries/complaints work related?
YesNo

Have you ever had similar complaints or injuries prior to this accident/injury?
YesNo

You Are @ Step 5 Now!

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Functional Rating Index

In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities. For each item below, please select each item which most closely describes your condition right now.

Rate Your Pain Intensity

Rate Your Sleeping

Personal Care (washing, dressing, etc.)

Travel (driving, etc.)

Working

Recreation

Frequency of Pain

Lifting

Walking

Standing

Any information that is not provided while filling out this form will need to be reviewed at the clinic on your first visit. By providing this information at this time, your initial appointment intake process will not be so lengthy. Your doctor will need a health history to complete the initial exam.

Additional forms will need to be signed when you arrive at the clinic on your first visit. Please bring a photo ID and any previous care information related to your accident if applicable. Thank you!

I will remember to Bring a photo IDI will also bring any previous care information related to my accidentI understand that I will need to Sign any additional forms when I arrive for my first visit

Formulario en Línea

Empecemos

Step 1 of 5 ( 20% )

INFORMACION DEL PACIENTE (*=Campos requeridos)

ASEGURANZA

En caso afirmativo, traiga la tarjeta del seguro médico a la oficina en su primera visita.

Información de seguro de automóvil|Auto Insurance Information

Si usted no tiene la información de la persona culpable con usted, por favor traiga esa información con usted en su próxima visita. Gracias!

RECORDATORIOS DE CITA

Pre-Injury Health History Questionnaire

Step 2 of 5 ( 40% )

Review of Symptoms

History

Social History

Past Medical History

Any surgeries PRIOR to injury?

Medications & Allergies

Please list below all prescription, over-the-counter or natural supplements you are taking

Dominant Hand

You Are @ Step 3 Now!

Step 3 of 5 ( 60% )

ACCIDENT INFORMATION

Select The Type of Accident You Had

"PERSONAL INJURY or SLIP/FALL"

Describe How and Where the injury occurred:

Upload INJURY Pictures

"MOTOR VEHICLE ACCIDENT (Patient)"

Motor Vehicle Information

MECHANISM OF INJURY

Upload MOTOR VEHICLE ACCIDENT Pictures

Upload INJURY Pictures

You Are @ Step 4 Now!

Step 4 of 5 ( 80% )

Post-Injury Questionnaire

SINCE THE ACCIDENT

ACTIVITIES OF DAILY LIVING

Work Status

GAP

You Are @ Step 5 Now!

Step 5 of 5 ( 100% )

Functional Rating Index

In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities. For each item below, please select each item which most closely describes your condition right now.

Rate Your Pain Intensity

Rate Your Sleeping

Personal Care (washing, dressing, etc.)

Travel (driving, etc.)

Working

Recreation

Frequency of Pain

Lifting

Walking

Standing

Additional forms will need to be signed when you arrive at the clinic on your first visit. Please bring a photo ID and any previous care information related to your accident if applicable. Thank you!

(972) 392-3400

Si usted no tiene la información de la persona culpable con usted, por favor traiga esa información
con usted en su próxima visita. Gracias!