Date: _________________ Office ID# _______

NEW CLIENT INTAKE FORM – PERSONAL INJURY

Name: _____________________________________

Address: ___________________________________ City: _______________ State: ______ Zip: _________

Preferred phone number: _______________________ Is this number your: cell, home, or work (please circle)

Email address: _______________________________ May we contact you via text and/or email? Yes No

Date of birth: ________________________________ Age: ______ Sex: M F

Occupation: __________________________________ Employer: ______________________________________

Status: M S W D Separated (please circle)

Names and ages of children, if any: _______________________________________________________________

Name of emergency contact: _________________________________ Relationship: ________________________

Emergency contact phone number: ____________________________

Purpose of this visit: ___________________________________________________________________________

If your purpose is a specific condition, has it occurred before? Yes No

If your purpose is a specific condition, when did it begin? ______________________________________________

Have you sought treatment previously for this condition? Yes No

Type of treatment: _______________________________ Results: ______________________________________

Doctors/Practitioners involved in treatment: _________________________________________________________

Is your condition: Job related Auto accident Home injury Other: _____________________________

Date of incident: ________________________________ Time of incident: ______________________________

Have you made a report of your incident to your employer or insurance company: Yes No

Are you currently taking: Nerve pills Pain medications/Muscle relaxers Blood pressure medicine Insulin

Do you suffer from any other conditions? Yes No If yes, please describe: ______________________

Do you have any allergies of any kind? Yes No If yes, please describe: ______________________

Do You Wear A Shoe Lift? Yes No

How did you hear about us? ___________________________________________________________________

Is there anyone specifically we can thank for referring you? __________________________________________

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**Payment is due at time of service. We are not a participating provider with any insurance companies. At your request, we can provide you with a

receipt of services that you can send to your insurance company for your reimbursement. If you have Medicare, or if this visit is related to an auto

accident or work accident, please see the front desk immediately for additional information and required paperwork**

PERSONAL HISTORY

Below are lists of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of chiropractic care.

Check any of the following conditions YOU have been diagnosed with or have a history of:___ Mumps ___ Measles ___ Pneumonia ___ Diabetes___ Rheumatic fever ___ Small pox ___ Pleurisy ___ Epilepsy___ Whooping cough ___ Chicken pox ___ Influenza ___ Cancer___ Tuberculosis ___ Polio ___ Anemia ___ Heart disease___ Arthritis ___ Eczema ___ Thyroid ___ Mental disorders___ Lumbago

Have you ever tested HIV positive? Yes No

Check any of the following YOU have experienced IN THE PAST 6 MONTHS:

MUSCULOSKELETAL EENT GASTRO-INTESTINAL___ Low back pain ____Vision problems ___ Poor or excessive appetite___ Pain between shoulders ____Ringing ears ___ Excessive thirst___ Neck pain ____Hearing loss ___ Frequent nausea___ Arm pain ____Ear aches ___ Vomiting ___ Joint pain/stiffness ____Stuffy nose/congestion ___ Diarrhea___ Walking problems ____Dental issues ___ Constipation___ Difficulty chewing/clicking jaw ____Sore throat ___ Hemorrhoids___ General stiffness ___ Gas/bloating after meals

___ HeartburnNERVOUS SYSTEM CARDIOVASCULAR ___ Black/bloody stool___ Nervousness/anxiety ___ Chest pain ___ Colitis___ Numbness ___ Shortness of breath ___ Liver problems___ Paralysis ___ Blood pressure issues ___ Gall bladder problems___ Dizziness ___ Irregular heartbeat ___ Weight issues ___ Cold/tingling extremities ___ Heart problems ___ Abdominal pain/cramps___ Convulsions ___ Lung issues___ Forgetfulness ___ Stroke___ Confusion ___ Ankle Swelling GENITO-URINARY___ Fainting ___ Varicose Veins ___ Bladder Trouble___ Depression ___ Painful/Excessive Urination

___ Discolored Urine___ Breast Pain/Lumps

GENERAL INTAKE ___ Prostate/Sexual Dysfunction___ Fatigue ___ Coffee___ Allergies ___ Tea FEMALES ONLY:___ Sleep issues ___ Alcohol Date of last period? ____________ Fever ___ Cigarettes/tobacco/nicotine products ___ Vaginal pain/infection

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___ Headaches ___ White Sugar ___ Menstrual irregularity___ Menstrual crampsAre you pregnant? Yes No Not sure

Please outline on the diagram any area(s) of discomfort you are experiencing:

Ache = A Numbness = N Pins & Needles = P Burning = B Stabbing = S Throbbing = T

FAMILY HISTORY

The following members have had or have similar problems/issues as I have had:

Mother___ Father___ Brother___ Sister___ Child___ Grandmother___ Grandfather___

Father: Living _____ Current age if still living: _____ Deceased _____ Cause and age at time of death if deceased: ____________________________________________________________________________________

Mother: Living _____ Current age if still living: _____ Deceased _____ Cause and age at time of death if deceased: ____________________________________________________________________________________

Please use the space below to provide any additional information or concerns:

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AUTO INSURANCE INFORMATION

Your Insurance Company ___________________________ Phone #: __________________________

Claim #: _________________________________________ Date of Accident: ___________________

Other Party’s Name: __________________________________________________________________

Other Party’s Ins. Co._______________________________ Phone #: __________________________

Claim #: ____________________________

Have you been contacted by an insurance adjustor regarding this claim? Yes No

If yes, name of adjustor: _____________________________ Company_________________________

Do you have an attorney that has advised you in this case? Yes No

If yes, attorney’s name_______________________________ Phone #: __________________________

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ACCIDENT QUESTIONNAIRE

Describe your vehicle that was involved in the incident:

1. Vehicle Type:

a. Sports Car

b. Coupe

c. Sedan

d. Sports Utility Vehicle

e. Station wagon

f. Pick-up truck

g. Bus

h. Other: __________________________

Make: _______________________________Year: ____________

Model: ________________________Estimated Speed: ________

Vehicle Size:

a. Compact

b. Mid-size

c. Full-size

Describe the incident:

3. Date of incident: __________________________________

4. Actions of the vehicle you were in:

a. Crossing an intersection

b. Stopped at an intersection

c. Stopped for a pedestrian

d. Stopped for traffic

e. Traveling at posted speed limit

f. Traveling faster than the posted speed limit

g. Turning

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5. How was your vehicle hit?

a. Hit head-on

b. Hit on the left front

c. Hit on the right front

d. Hit on the left rear

e. Hit on the right rear

f. Rear-ended

g. Other: _______________________________

6. Damage to your vehicle:

a. Complete

b. Extensive

c. Minimal

d. Moderate

7. Describe the second vehicle:

a. Compact

b. Full-size

c. Mid-size

d. Semi/tractor trailer

e. Pick-up truck

Make: ___________________________ Year: ____________

Model: ______________________ Estimated Speed: _________

8. Damage to the other vehicle?

a. Complete

b. Extensive

c. Minimal

d. Moderate

9. Weather Conditions

a. Clear e. Rainy

b. Cloudy f. Snowy

c. Drizzling g. Stormy

d. Foggy h. Sunny

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10. Road Conditions

a. Damp

b. Dry

c. Dry with icy patches

d. Iced over

e. Snow covered

f. Wet

Describe the moment of impact:

11. Body position at time of impact:

a. Leaning forward

b. Slouched down in seat

c. Straight

d. Turned to the left

e. Turned to the right

12. Direction body was thrown:

a. Backward then forward

b. Forward then backward

c. To the left

d. To the right

e. About the vehicle

f. Outside the vehicle

g. Under the vehicle

13. Head position at impact:

a. Straight

b. Tilted forward

c. Turned to the left

d. Turned to the right

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14. Direction head was thrown:

a. Backward then forward

b. Forward then backward

c. Side to side

15. Type of restraint:

a. Lap belt

b. Shoulder belt

c. Shoulder lap belt

16. Place you were seated in the vehicle:

a. Driver

b. Front passenger

c. Back passenger driver side

d. Back passenger right side

e. Back passenger middle

f. Other_________________________________

17. Did Airbags deploy:

a. Yes

b. No

18. Were you seen at a Medical Facility following the incident?

a. Yes

b. No

If yes, name and address of the facility:

________________________________________________________________________________________

Patient Signature: _________________________________________ Date: _______________________

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SYMPTOMS ASSOCIATED WITH THE INCIDENT

Patient’s Name_____________________________ Date of incident ___________Today’s Date____________

Please circle any complaints/symptoms you are experiencing since the incident:

2. Lacerations, cuts, or bruising:a. Head or Faceb. Neckc. Seat belt bruising d. Cuts or bruising on your cheste. Cuts or bruising on armsf. Cuts or bruising on legsg. Other: __________________________

3. Neck issues:

a. Neck painb. Neck pain, numbness, tingling, weakness that radiates or goes to RIGHT shoulder, arm, forearm, or handc. Neck pain, numbness, tingling, weakness that radiates or goes to LEFT shoulder, arm, forearm, or hand d. Neck pain, numbness, tingling, weakness that radiates or goes down to RIGHT upper backe. Neck pain, numbness, tingling, weakness that radiates or goes down to LEFT upper backf. Neck pain that causes headaches g. Neck spasms or shoulder spasms h. Popping, clicking, or clunking sound with neck movement

4. Jaw issues:a. Jaw painb. Clickingc. Pain while chewingd. Pain while talkinge. Pain while yawningf. Pain while moving jaw from side to side

5. Shoulder issues:a. Shoulder pain Right Left Bothb. Shoulder pain with movement Right Left Bothc. Shoulder spasms Right Left Bothd. Sharp shoulder pain Right Left Bothe. Dull shoulder pain Right Left Bothf. Achy shoulder pain Right Left Bothg. Pins and needles shoulder pain Right Left Bothh. Shoulder pain that radiates or shoots pain into arm Right Left Bothi. Other: _______________________________

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6. Head Injuries:a. Were you knocked out or unconscious? b. Headaches c. Face paind. Pupils different sizese. Dizzinessf. Difficulty walkingg. Balance problemsh. Room spinsi. Disoriented Confusionj. Day dreaming k. Attention problemsl. Hearing problemsm. Change in sense of smell or tasten. Difficulty speakingo. Memory problemsp. Very tired or fatiguedq. Appetite changer. Sleep difficulties s. Visual disturbances, blurry, or double vision t. Flashbacks to accidentu. Problems to read or writev. Problems adding or subtractingw. Problems learning new thingsx. Problems understandingy. Problems remembering numbersz. Difficulty Concentrating aa. Difficulty remembering thingsab. Difficulty making decisionsac. Change in sexual functioningad. Nausea / Vomiting ae. Change of personalityaf. Wanting to be aloneag. Mood swings ah. Sadnessai. Agitationaj. Angerak. Helplessnessal. Reduce confidenceam.Apathyan. Irritabilityao. Sleepiness ap. Frustrationaq. Impatiencear. Other head related issues _________________________________

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7. Upper arm issues: Right Left BothPlease describe: a. Dull painb. Achec. Sharp paind. Stabbing paine. Other _________________________________

8. Elbow issues: Right Left Both a. Dull pain b. Ache c. Sharp pain d. Stabbing pain e. Other _________________________________

9. Forearm issues: Right Left Botha. Dull painb. Achec. Sharp paind. Stabbing paine. Other __________________________________

10. Wrist issues: Right Left Botha. Dull painb. Achec. Sharp paind. Stabbing paine. Other _________________________________

11.Hand issues: Right Left Botha. Dull painb. Achec. Sharp paind. Stabbing paine. Other _________________________________

12. Upper/mid back issues:a. Upper or mid back pain b. Upper back pain, numbness, tingling, weakness that radiates or goes to RIGHT shoulder, arm, forearm, or

handc. Upper back pain, numbness, tingling, weakness that radiates or goes to LEFT shoulder, arm, forearm, or

hand d. Upper or mid back spasms

13. Low back issues:a. Low back painb. Low back pain, numbness, tingling, weakness that radiates or goes to RIGHT buttock, thigh, leg, or footc. Low back pain, numbness, tingling, weakness that radiates or goes to LEFT buttock, thigh, leg or footd. Low back spasms

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14. Pelvic/sacral issues:a. Pelvic pain, numbness, tingling, weakness that radiates or goes to RIGHT buttock, thigh, leg or footb. Pelvic pain, numbness, tingling, weakness that radiates or goes to LEFT buttock, thigh, leg or footc. Sacral pain (tail bone)d. Coccygeal or coccyx (tail bone) pain

15. Hip issues: Right Left Botha. Hip painb. Hip pain, numbness, tingling, weakness that radiates or goes to buttock, thigh, leg or foot

16. Upper leg issues: Right Left Both

a. Upper leg pain that radiates to knee

b. Upper leg spasms

17. Knee issues: Right Left Both

a. Knee pain that radiates to calf

b. Knee pain that radiates to calf and ankle

c. Knee pain that radiates to calf, ankle, and foot

18. Ankle issues: Right Left Both

a. Ankle pain that radiates to foot

b. Ankle and foot pain

19. Foot pain: Right Left Both

20. Chest pain: Yes No

21. Stomach/abdominal pain: Yes No

22. Please describe any other issues you may be having since the incident: __________________________________________________________________________________________

__________________________________________________________________________________________

23. In your own words, please describe the incident:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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Patient Name: ________________________

DIET AND EXERCISE ASSESSMENT

If I were to describe my diet it would be: Poor Fair Good Excellent

Please write out an example of daily your food consumption:

Breakfast: ____________________________________________________________________________________

Lunch: ______________________________________________________________________________________

Snacks: ______________________________________________________________________________________

Dinner: ______________________________________________________________________________________

Do you eat at regularly scheduled times? Yes No Sometimes

How many ounces of water do you drink in a day? ____________

Do you exercise? Yes No If yes, type and how often? ______________________________________

Do you supplement with vitamins or other nutritional products? Yes No

If YES, are you consistent? Yes No

Please list any supplements and brand names you are using: ____________________________________________

____________________________________________________________________________________________

Please list any medications you are currently taking: __________________________________________________

____________________________________________________________________________________________

On average, how many hours of sleep do you get? _______ Is your sleep restful? Yes No

What position do you sleep in? Back Side Stomach

Please describe your work day or daily routine: _____________________________________________________

___________________________________________________________________________________________

What are your top 3 goals while receiving chiropractic care? 1.______________________________2. ______________________________3. ______________________________

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Why chiropractic? People go to Chiropractors for a variety of reasons. Some go for symptomatic relief or pain or discomfort (Relief Care). Other are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your doctor will weight your needs and desires when recommending your treatmentprogram.

Please check the type of care desired so that we may be guided by your wishes whenever possible.___ Relief Care ___ Corrective Care ___ Doctor Recommendation

RELIEF CARE CORRECTIVE CARERelief Care is that care necessary to get rid of your Corrective care differs from relief care in that itssymptoms or pain, but not the cause if it. It is the goal is to get rid of the symptoms or pain whilesame as drying a floor that is getting wet from a correcting the cause of the problem. Corrective leak, but not fixing the leak. care varies in length of time, but is more lasting.

I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate, any fees for professional services rendered me will be immediately due and payable.

I hereby authorize the Doctor to treat my condition as he or she deems appropriate through use of manipulation throughout the spine. It is understood and agreed the amount paid the Doctor, is for examination and x-rays only. The x-ray negatives will remain the property of the office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions, nor for any medical diagnosis.

Patient Signature: ___________________________________ Date: _____________________

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Guardian Signature: _________________________________ Date: _____________________

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AUTHORIZATION AND RELEASE:

I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor torelease all information necessary to communicate with personal physicians and other healthcare providers and payers and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determinedby my treating doctor, any fees for professional services will be immediately due and payable.

The patient understands and agrees to allow this chiropractic office to use their Patient Health Informationfor the purpose of treatment, payment, healthcare operations, and coordination of care. We want you toknow how your Patient Health Information is going to be used in this office and your rights concerning thoserecords. If you would like to have a more detailed account of our policies and procedures concerning theprivacy of your Protected Health Information, we encourage you to read the HIPAA NOTICE that isavailable to you at the front desk before signing this consent. If there is anyone you do not want to receiveyour medical records, please inform our office.

Notice of Privacy Practices Consent Acknowledgement

My signature below confirms I have been informed of my rights to privacy regarding my protected health information under the Health Insurance Portability & Accountability Act of 1996 (HIPPA). I understand this information can and will be used to:

Provide and coordinate my treatment among a number of health careproviders who may be involved in my treatment directly and indirectly.

Obtain payment for third-party carriers for my health services. Conduct normal health care operations such as assessment and improvement activities.

I have been informed of my health care providers Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to change the Notice of Privacy Practices. I understand that my provider has the right to change the Notice of Privacy Practices and that I may contact this office at this office at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I understand you are not required to agree to my requested restrictions, but if you do agree, you are bound to abide by such restrictions.I have been informed of my Notice of Privacy Practices on the following date(s):

Patients name (please print): ______________________________________________________________

Signature of patient or guardian: __________________________________ Date: ____________________

Relationship to patient: ___________________________________________________________________

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We are glad you have entrusted our office with your health care. To provide you with quality, timely care, we need your cooperation with certain matters to make sure every client has his/her needs met.

Insurance

We are not participating providers with any insurance companies. At your request, we can provide you with a receipt of services thatyou can send to your insurance company for your reimbursement.

Payment

Payment for services is due at the time of service. We accept cash, checks, MasterCard, Visa, Discover Card, and American Express.There is a $25 charge for any returned checks. Balances beyond 30 days will be charged an additional 1.5%. If account is not paid within90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees,and any other expenses incurred in collecting your account.

Medicare

Discover Life Chiropractic is a non-participating provider. Payment for all services is due at the time of service. We will then submit yourclaims to Medicare. Medicare and your secondary (if applicable) will reimburse you directly. Medicare limits reimbursement for services performed by a chiropractor to spinal adjustments only.

Cancellation & Missed Appointment Policy

We require a minimum of a 24-hour notice when a patient cancels their appointment. When a patient does not show up for anyappointment or cancels with less than a 24-hour notice, a $25 fee will be charged to the patient. With three missed appointments, thepatient may be asked to transfer their records to another doctor.

Workers Compensation

We require written approval/authorization by your employer and/or worker’s compensation carrier prior to your initial visit. If your claim is denied, you will be responsible for payment in full.

Personal Injury

Discover Life Chiropractic will accept assignment for Personal Injury Cases with a signed lien. Understand, ultimately it is the patient who is responsible for the accrued balance.

X-Rays

All X-rays taken in this office are the property of this office. Any copies needed are subject to a $35 per X-ray copy fee. Copies of X-raysmay take up to 10 days to complete.

Authorization

I authorize the staff to perform any necessary services needed during diagnosis and treatment. I authorize Dr. P. Paige Mott/Discover Life Chiropractic to release any information concerning my physical condition which may be

deemed appropriate and necessary to an insurance company/adjuster, billing agent, or attorney in order to process any claims for reimbursement of charges by me as a result of professional services rendered by Dr. P. Paige Mott, DC.

This is the entire agreement between Discover Life Chiropractic and the patient below. I have read this agreement, understand it and agree with its provisions. I received a copy of it at the time of signing it below.

__________________________________________________________ ____________________________Signature of patient or guardian Date

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ASSIGNMENT OF BENEFITS: ASSIGNMENT OF CAUSE OF ACTION: CONTRACTUAL LIEN

The undersigned patient and / or responsible party, in addition to continuing personal responsibility, and in consideration of treatment rendered or to be rendered assigns to Discover Life Chiropractic, the following rights, power and authority:

RELEASE OF INFORMATION: You are authorized to release information concerning my condition and treatmentto my insurance company, attorney or insurance adjuster for purposes of processing my claim for benefits and payment of services rendered to me.

IRREVOCABLE ASSIGNMENT OF RIGHTS: You are assigned the exclusive, irrevocable right to any cause of action that exists in my favor against any insurance company for the terms of the policy, including the exclusive, irrevocable right to receive payment for such services, make demand in my name for payment, and prosecute and receive penalties, interest, court loss, or other legally compensable amounts owned by an insurance company in accordance with the Colorado Unfair Claims Practice Act, Revised Statute Section 10-3-1104 to cooperate, provide information as needed, and appear as needed, wherever to assist in the prosecution of such claims for benefits upon request.

DEMAND FOR PAYMENT: To any insurance company providing benefits of any kind to me / us for treatment rendered by the physician facility named above, you are hereby tendered demand to pay in full the bill for services rendered by the physician / facility named above within 30 days following your receipt of such bill for services to the extent such bills are payable under the terms of the policy. This demand specifically conforms to the Colorado Unfair Claims Practice Act, Revised Statute Section 10-3-1104, providing for attorney fees, 18% penalty, court cost,and interest from judgment, upon violation. I further instruct the provider to make all checks payable to Discover Life Chiropractic, and to send all checks to 2216 Hoffman Drive, Unit A, Loveland, CO 80538.

THIRD PARTY LIABILITY: If my injuries are the result of negligence from a third party, then I instruct the Liability carrier to cut a separate draft to pay in full all services rendered, payable to Discover Life Chiropractic, 2216 Hoffman Drive, Suite A Loveland, CO 80538.

STATUTE OF LIMITATIONS: I waive my rights to claim any statute of limitations regarding claims for services rendered or to be rendered by the physician / facility named above, in addition to reasonable cost of collection, including attorney fees and court cost incurred.

LIMITED POWER OF ATTORNEY: I hereby grant to the physician / facility named above the power to endorse my name upon any checks, drafts, or other negotiable instrument representing payment from any insurance company representing payment for treatment and healthcare rendered by the physician / facility named above. I agree that any insurance payment representing an amount in excess of the charges for treatment rendered will be credited to my / our account or forwarded to my / our address upon request in writing to the physician / facility named above.

PATIENT RESPONSIBILITY: I understand and agree that I am 100% directly and fully responsible to said MedicalProvider for all medical services rendered and bills issued pursuant to this Contractual Lien:

(a) Even if any insurance company denies payment in whole or part for such medical services;

(b) Even if patient is forced to file a lawsuit due to denial of payments by an insurance claims adjuster; and

(c) Even if a judge or jury renders a verdict in my lawsuit that the insurance company for said person or entityis not responsible for payment for Patient’s medical bills.

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REJECTION IN WRITING: I hereby authorize the physician / clinic named above to establish a MedPay or UM/UIM claim on my behalf. I also instruct my insurance carrier to provide upon request to the provider / clinic named above, any rejections in writing as they apply to my lack of MedPay or UM/UIM coverage. If my carrier is unable to provide said rejections in a timely manner, I acknowledge that I am entitled to minimum levels of coverage, as per section 10-4-635 of the Colorado Revised Statute, and further instruct my carrier to pay up to available limits directly to physician / clinic named above, and to send any and all checks or financial instruments to Discover Life Chiropractic at 2216 Hoffman Drive, Unit A, Loveland, CO 80538.

TERMINATION OF CARE: I hereby acknowledge and understand that if I do not keep appointments as recommended to me by my caring doctor at this clinic, he / she has full and complete right to terminate responsibility for my care and relinquish any disability granted me within a reasonable period of time. If during thecourse of my care, my insurance company requires me to take an examination from any other doctor; I will notify this physician / facility immediately. I understand that failure to do so may jeopardize my case.

Signature of patient and / or responsible parties:

Patient: ____________________________________________ Date: ______________________

Medical Provider: _____________________________________ Date: ______________________

Attorney: ___________________________________________ Date: _____________________

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