Yen Chiropractic, LLC Personal Injury Patient Intake Form Page 1
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1 GENERAL INFORMATION: TODAY'S DATE: YEN CHIROPRACTIC DR. DANIEL D. YEN, D.C W CRAIG RD, SUITE 190 NORTH LAS VEGAS, NV PATIENT NAME: SOCIAL SECURITY #: ADDRESS: CITY: STATE: ZIP: SEX: ( ) FEMALE ( ) MALE BIRTH DATE: HEIGHT: AGE: WEIGHT: ( ) MARRIED ( ) WIDOWED ( ) SINGLE ( ) MINOR ( ) SEPARATED ( ) DIVORCED ( ) PARTNERED FOR YEARS HOME PHONE: CELL PHONE: BEST TIME AND PLACE TO REACH YOU: OCCUPATION: PATIENT EMPLOYER/SCHOOL: EMPLOYER/SCHOOL ADDRESS: EMPLOYER/SCHOOL PHONE: HOW DID YOU HEAR ABOUT US?: IN CASE OF EMERGENCY, CONTACT: NAME: RELATIONSHIP: HOME PHONE: CELL PHONE: INFORMATION ABOUT THE ACCIDENT: DATE OF LOSS/ACCIDENT: INSURANCE CLAIM #: ATTORNEY NAME & PHONE: Yen Chiropractic, LLC Personal Injury Patient Intake Form Page 1
2 DESCRIBE THE ACCIDENT IN DETAIL: SPECIFICS OF THE ACCIDENT: (MARK EACH THAT APPLY TO THE ACCIDENT) JOB/WORK RELATED INJURY: YOU WERE THE: ( ) DRIVER ( ) PASSENGER SITTING IN THE: ( ) FRONT SEAT ( ) BACK SEAT BEFORE THE COLLISION, DID YOU: ( ) BRACE YOURSELF ( ) DID NOT BRACE YOURSELF DURING THE COLLISION, DID YOUR HEAD: ( ) STRIKE AN OBJECT ( ) DID NOT STRIKE AN OBJECT DURING THE COLLISION, DID YOU EXPERIENCE: ( ) SHOCK ( ) FLASH OF LIGHT SEEN UPON IMPACT DURING THE COLLISION, DID YOUR AIR BAG: ( ) DEPLOY ( ) DID NOT DEPLOY IMMEDIATELY FOLLOWING THE ACCIDENT (CHECK ALL THAT APPLY): ( ) AMBULANCE-PARAMEDICS CALLED ( ) TREATED AT SCENE ( ) TRANSPORTED TO HOSPITAL BY AMBULANCE ( ) WENT TO HOSPITAL ON OWN WILL ( ) DIAGNOSTICS PERFORMED AT HOSPITAL ( ) MEDICATION PRESCRIBED ( ) TREATMENT AT HOSPITAL ( ) A FOLLOW-UP WAS RECOMMENDED Yen Chiropractic, LLC Personal Injury Patient Intake Form Page 2
3 TIME LOSS SINCE THE ACCIDENT: ( ) NO TIME LOSS FROM WORK DUE TO INJURY. I AM CURRENTLY WORKING WITH NO LIMITATIONS. ( ) NO TIME LOSS FROM WORK DUE TO INJURY, BUT I DO HAVE LIMITATIONS. PLEASE DESCRIBE YOUR LIMITATIONS: ( ) I HAVE EXPERIENCED TIME LOSS FROM WORK DUE TO INJURY. PLEASE INDICATE NUMBER OF LOST DAYS, WEEKS, ETC. ( ) THE ABOVE DOES NOT APPLY TO ME. MECHANISM OF INJURY: WERE YOU SURPRISED BY THE IMPACT? IN RELATION TO THE BACK OF YOUR HEAD, WAS YOUR HEADREST: ( ) LOW ( ) MIDDLE ( ) HIGH ( ) NONE WERE YOU LEANING FORWARD AT THE TIME OF THE IMPACT? WERE YOU WEARING A SEATBELT/HARNESS? WERE YOU RENDERED UNCONSCIOUS AS A RESULT OF THE ACCIDENT? DID YOU FEEL PAIN IMMEDIATELY AFTER THE ACCIDENT? DID YOU LEAN YOUR BODY TOWARDS THE LEFT OR RIGHT BEFORE THE IMPACT? LIST THE YEAR AND TYPE OF VEHICLE YOU WERE IN: SIZE OF THE VEHICLE YOU WERE IN: ( ) SMALL ( ) MIDSIZE ( ) LARGE ( ) UNKNOWN LIST THE YEAR AND TYPE OF OTHER VEHICLE INVOLVED IN THE ACCIDENT: Yen Chiropractic, LLC Personal Injury Patient Intake Form Page 3
4 SIZE OF THE OTHER VEHICLE: ( ) SMALL ( ) MIDSIZE ( ) LARGE ( ) UNKNOWN WHAT WAS THE APPROXIMATE SPEED OF YOUR VEHICLE WHEN THE ACCIDENT OCCURRED? WHAT WAS THE APPROXIMATE SPEED OF THE OTHER VEHICLE WHEN THE ACCIDENT OCCURRED? SOCIAL HISTORY: NUMBER OF CHILDREN YOU HAVE: ( ) SMOKER ( ) NON-SMOKER ( ) DRINKS ALCOHOL ( ) DOES NOT DRINK ALCOHOL ( ) TAKES DRUGS ( ) DOES NOT TAKE DRUGS LIST YOUR HOBBIES AND EXERCISE ACTIVITIES: MEDICAL HISTORY: I HAVE PREVIOUSLY SEEN THE FOLLOWING PHYSICIAN/PRACTITIONERS FOR THIS ACCIDENT: CHIROPRACTOR: MASSAGE THERAPIST: NEUROLOGIST: ORTHOPEDIST: PHYSICAL THERAPIST: PHYSICIAN: PSYCHIATRIST/PSYCHOLOGIST: OTHER: CHECK THE TREATMENTS YOU HAVE ALREADY HAD FOR THIS CONDITION: ( ) ICE ( ) HEAT/ULTRASOUND ( ) ELECTRICAL STIMULATION ( ) EXERCISES ( ) GRAVITY INVERSION-TRACTION ( ) BED REST ( ) CHIROPRACTIC ( ) OSTEOPATHY ( ) INJECTIONS ( ) ACUPUNCTURE ( ) NATUROPATHY ( ) MASSAGE Yen Chiropractic, LLC Personal Injury Patient Intake Form Page 4
5 IF ANY, LIST PREVIOUS BACK, NECK AND OTHER MUSCULOSKELETAL PROBLEMS: HAVE YOU HAD ANY PREVIOUS OR SUBSEQUENT ACCIDENTS? IF SO, PLEASE LIST THE DATES THAT YOU LAST TREATED OR HAD COMPLAINTS: SINCE THE MOST RECENT ACCIDENT DO YOU FEEL YOU ARE TROUBLED WITH: ( ) ANXIETY ( ) DEPRESSION ( ) IRRITABILITY LIST CURRENT MEDICATIONS: LIST PAST SURGERIES: LIST PAST HOSPITALIZATIONS: CHECK THE TYPES OF DIAGNOSTIC TESTING THAT HAS BEEN DONE FOR THIS ACCIDENT: ( ) X-RAYS ( ) CT SCAN ( ) MYELOGRAM ( ) MRI ( ) DISCOGRAM ( ) BONE SCAN ( ) EMG FOR FEMALES ONLY: ARE YOU PREGNANT: CHECK IF YOU HAVE THE FOLLOWING: ( ) VAGINAL BLEEDING OTHER THAN A PERIOD ( ) PAP SMEAR WITHIN THE LAST 2 YEARS ( ) PAINFUL MENSTRUAL PERIODS ( ) BACK PAIN ( ) OTHER MENSTRUAL PROBLEMS CHECK IF YOU HAVE EVER HAD ANY OF THE FOLLOWING SYMPTOMS: ( ) AIDS/HIV ( ) NEED TO URINATE MORE AT NIGHT ( ) ALCOHOLISM ( ) NIGHT SWEATS Yen Chiropractic, LLC Personal Injury Patient Intake Form Page 5
6 ( ) ALLERGY SHOTS ( ) OSTEOPOROSIS ( ) ANEMIA ( ) PACEMAKER ( ) ANOREXIA ( ) PAIN/BURNING WHEN URINATING ( ) APPENDICITIS ( ) PARKINSON S DISEASE ( ) ARTHRITIS ( ) PERSISTENT DIARRHEA ( ) BLEEDING DISORDERS ( ) HIGH BLOOD PRESSURE ( ) BLOOD IN STOOLS ( ) HIGH CHOLESTEROL ( ) BLOOD IN URINE ( ) JOINT PAIN OR SWELLING ( ) BREAST LUMP ( ) KIDNEY DISEASE ( ) BRONCHITIS ( ) LIVER DISEASE ( ) BULIMIA ( ) LOSS OF APPETITE ( ) CANCER ( ) LUMPS IN NECK, ARMPIT OR GROIN ( ) CATARACTS ( ) MEASLES ( ) CHANGE IN BOWL HABITS ( ) MIGRAINE HEADACHES ( ) CHEMICAL DEPENDENCY ( ) MISCARRIAGE ( ) CHEST PAIN OR TIGHTNESS ( ) MONONUCLEOSIS ( ) CHICKEN POX ( ) MORNING STIFFNESS ( ) COUGHING UP BLOOD ( ) MUMPS ( ) DIABETES ( ) MUSCLE TENDERNESS ( ) DARK BLACK STOOLS ( ) PERSISTENT EYE REDNESS ( ) DIFFICULTY SLEEPING ( ) PERSISTENT OR UNUSUAL COUGH ( ) DIFFICULTY URINATING START-STOP ( ) PINCHED NERVE ( ) DRY EYES OR MOUTH ( ) PNEUMONIA ( ) EASY BRUISING ( ) POLIO ( ) EMPHYSEMA ( ) PROSTATE PROBLEM ( ) EPILEPSY ( ) PROSTHESIS ( ) EXCESSIVE BLEEDING ( ) PSYCHIATRIC CARE ( ) EXCESSIVE CONSTIPATION ( ) RHEUMATOID ARTHRITIS ( ) EXCESSIVE FATIGUE ( ) RHEUMATIC FEVER ( ) FRACTURES ( ) SEXUALLY TRANSMITTED DISEASE ( ) GLAUCOMA ( ) SKIN RASHES ( ) GOITER ( ) STOMACH PAIN ( ) GONORRHEA ( ) STROKE Yen Chiropractic, LLC Personal Injury Patient Intake Form Page 6
7 ( ) GOUT ( ) SUICIDE ATTEMPT ( ) HEART DISEASE ( ) SWOLLEN ANKLES ( ) HEPATITIS ( ) THYROID PROBLEM ( ) HERNIA ( ) TONSILLITIS ( ) HERNIATED DISK ( ) TROUBLE BREATHING WITH EXERCISE ( ) HERPES ( ) TROUBLE BREATHING WITH LYING FLAT ( ) TUBERCULOSIS ( ) TUMORS, GROWTHS ( ) TYPHOID FEVER ( ) ULCERS ( ) UNEXPLAINED FEVERS ( ) UNUSUAL STRESS AT HOME ( ) UNUSUAL STRESS AT WORK ( ) VAGINAL INFECTIONS ( ) WEIGHT LOSS OF 10 LBS OR MORE ( ) WHOOPING COUGH TODAY'S DATE: PRINT YOUR NAME: SIGN YOUR NAME: PRINT THE GUARDIAN NAME IF UNDERAGE: SIGNATURE OF GUARDIAN IF UNDERAGE: Yen Chiropractic, LLC Personal Injury Patient Intake Form Page 7
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