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OUR STORY
WHO WE ARE
WHAT TO EXPECT
CONTACT
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Please complete the form below
Workers Compensation
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
Date of Birth
*
MM
DD
YYYY
Gender
*
Male
Female
Primary Care Physician
Occupation
*
Employer
*
Lost Days of Work
*
Yes
No
Marital Status
*
Single
Married
Divorced
Widowed
Spouse's Name
Emergency Contact
Emergency Contact Phone Number
Necessary Administrative Information
Claim Number
Insurance Adjuster's Name
First Name
Last Name
Insurance Adjuster's Phone
(###)
###
####
Insurance Adjuster's Fax
(###)
###
####
Insurance Adjuster's Email
Have you retained an attorney?
*
Yes
No
Attorney's Name
First Name
Last Name
Firm Name
Attorney/Firm Phone
(###)
###
####
Workers' Compensation Questionnaire
Did you report the injury to your employer?
Yes
No
Have you lost days of work?
Yes
No
Were you hospitalized?
Yes
No
If yes, which hospital?
Did you consult with another doctor (MD, DC , PT, Etc)?
Yes
No
If yes, please explain
Date of the accident
*
MM
DD
YYYY
Please the described he incident in detail
*
Symptoms at time of incident (immediately following)?
Symptoms currently experiencing (if different)?
If the work injury involved a motor vehicle, complete this section (if not move to next section)
Was there anyone in the car with you?
Yes
No
If yes, who?
Were you wearing a seat belt?
Yes
No
Your position in vehicle
*
Driver
Front - passenger
Back seat behind driver
Back seat behind front passenger
Middle back seat
Was your vehicle struck from...
Front
Behind
Left (Driver's) Side
Right (Passenger) Side
Was not struck
Were you....(your vehicle)
At a stop
Moving
What type of vehicle were you driving?
What type of vehicle struck you?
Were police present at the scene?
Yes
No
Was a police report filed?
Yes
No
How fast was the vehicle traveling at the time of the accident?
How fast was your vehicle traveling at the time of the accident?
Was there a secondary collision?
Yes
No
Did you prepare (brace yourself) for impact/collision?
Yes
No
Did you hit your head?
Yes
No
Did you get 'knocked out' (loss of consciousness)?
Yes
No
Did the airbag deploy?
Yes
No
Did you experience a 'whiplash' type injury?
Yes
No
Was an ambulance present?
Yes
No
Did you go to the emergency department?
Yes
No
If yes, what hospital?
What tests/exams/imaging/procedures were done at the hospital?
Did you consult with another doctor (MD, DC, PT, Etc)?
Yes
No
If yes, please explain
Have you missed days of work due to motor vehicle accident (and or injuries)?
Yes
No
Unemployed
Retired
History of Complaint
First Complaint
*
In your words, how would you describe the pain? (examples: ache, burning, numbness)
*
On a scale from 0 to 10 with 10 being the "worst pain you have ever felt" and 0 being no pain, how would you rate your discomfort?
*
Date of Onset (when did it begin)
*
MM
DD
YYYY
How often do you experience the pain?
*
Constant
On/off throughout the day
Comes and goes throughout the week
What time of day is the problem the worst?
*
AM
Mid-day
PM
Late PM
No specific time of day
Does the pain/discomfort radiate into your extremities?
*
Yes
No
If yes please explain
Second Complaint
In your words, how would you describe the pain? (examples: ache, burning, numbness)
On a scale from 0 to 10 with 10 being the "worst pain you have ever felt" and 0 being no pain, how would you rate your discomfort?
Date of Onset
MM
DD
YYYY
How often do you experience the pain/discomfort?
Constant
On/off throughout the day
Comes and goes throughout the week
What time of day is the problem the worst?
AM
Mid-day
PM
Late PM
Does the pain/discomfort radiate into your extremities?
Yes
No
If yes please explain:
Do you have more than two complaints?
*
*If yes, we will discuss in-person with the doctor.
Yes
No
Following the work injury, have you experienced any of the following health challenges? Please check all that apply.
General
Fatigue
Fever(s)
Unexplained weight loss
Insomnia
Ears, Eyes, Nose & Throat
Visual changes
Hearing loss
Sore throat
Trouble swallowing
Nasal congestion
Ear pain
Respiratory
Prolonged cough
Unable to catch breath
Wheezing
Snoring
Cardiovascular Issues
Irregular heartbeat
Racing heart
Chest pain
Swelling of legs or feet
Shortness of breath
Musculoskeletal
Joint pain
Muscle pain
Neurologic
Headaches
Dizziness
Difficulty walking
Numbness or tingling in face
Seizures
Gastro-Intestinal Issues
Abdominal pain
Constipation
Diarrhea
Gas
Heartburn
Nausea
Vomiting
Genitourinary
Painful urination
Bloody urine
Increased urination
Leaking urine
Females Only
Ionizing radiation can be hazardous to an unborn child.
To the best of my knowledge I am not pregnant and the doctor has my permission to perform an x-ray evaluation.
I am currently, pregnant and therefore I am unable to receive ionizing radiation at this time.
Are you trying to become pregnant?
Yes
No
If yes, have you had trouble conceiving?
Yes
No
Do you suffer with any of the following?
Check all that apply
PMS
Painful monthly cycle
Absent monthly cycle
Heavy menstrual cycle
Abnormal vaginal discharge
Polycystic Ovarian Syndrome
Check the box if you were not prescribed any medications following the work injury
I was not prescribed any medications
List any medications prescribed following the work injury:
Standard Waiver of Liability
Please read and confirm the following statement
*
I authorize my insurance benefits to be paid directly to this office (New Beginnings Chiropractic). I authorize the doctor to release any and all medical information required to assist in collecting fees from my insurance company. In the event that I fail to pursue/prosecute the claim, for this injury/condition, or it is determined at a hearing by a judge, that the injury/condition is not a direct result of said motor vehicle accident, I hereby agree to pay New Beginnings Chiropractic their usual and customary fees for the services rendered to me in this case
Informed Consent
Chiropractic is a art, science, and philosophy which concerns itself with the relationship between the spinal structure and the health of the central nervous system. Any disturbance to the CNS will create sickness and disease. One such disturbance to the nervous system is known as a vertebral subluxation. This occurs when one or more of the 24 vertebra in the spinal column become misaligned and/or do not move properlycreating nerve interference which may result in pain and dysfunction or may be entirely asymptomatic. In order to reduced or correct the vertebral subluxation the doctor will be using his/her hands to gently move the vertebra back in to a healthier position. At which time, you may feel a sense of movement of the vertebra and hear an audible “pop” or “click”. The sound created is completely natural and is merely a release of gas within the joints of the spine. Chiropractic care has been proven to be extremely safe and effective; however, it is not unusual to be sore after your first few specific chiropractic adjustments. Other commonly reported side effects include muscle spasm(s), stiffness, headaches, and dizziness. Although extremely rare, rib fracture has been reported but is (typically) due to an underlying condition being present. Imaging helps us rule in/out the presence of such conditions. If at the beginning or during the course of care we encounter a non-chiropractic issue we will refer you out to the appropriate health care provider. I have the right, as a patient, to be informed about the condition and the recommended care to be provided so that I can make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks, and alternatives.
*
I have read and fully understand the above statements and therefore accept chiropractic care on this basis. By checking the box, I am consenting to care.
Thank you! We will contact you ASAP.
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