c h 官諜†i - bent chiropracticbentchiropractic.com/wp-content/uploads/2018/05/img002.pdf ·...
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官諜†i 。
Notice of Health Practitionerしien
Notice is hereby given, Dr. Amber Bent, D.C" / Dr. Matt Herrin, D・C. at 1600 Gravois Rd′ High
Ridge, Mo 63049, rendered chiropractic and other heaIth care treatment and se「vices to‥
for persona=njuries on or about fo「 which
is a=eged as =abIe. Dr. Ambe「 Bent, D.C. /Dr. Matt Herrin, D.C.
hereby cIaims a lien for services rendered through
upon a= claims′ demands suit or rights of action by
inthe amountof
and which a=ege liab描ty is insured by
Authorization to Pay Benefits
l hereby authorize paYment directIy to the provider of medicaI benefits what would be due. l
hereby authorize mY attOrney言nsurance company, to pay di「ectiyto
the provider such sums which may be due as result ofthis accident and to withhold such sums
from any settIement, judgement r verdict as maybe necessary to adequatelY PrOteSt Said doctor
o「dinic.
Patient signature:
。○○⑱瑞㊨。。hC
Car lnsu「ance Company:
Address:
Adj uste「: Phone #:
Po=cy Number:
Drive「s License #:
Lawye「/Law Fi「m :
Address:
Phone #:
Claim #:
Phone #:
Accident Questionnai「e
Patient Name
Date of inju「Y
Describe vour vehicie
l. VehicleType
a) Sp〇億SCa「
b〉 Coupe
C〉 Sedan
d) SUV
e) StationWagon
f) Pick-uPTruck
Make: Year:
ModeI:
2. VehicIeSize
a. Compact
b. Mid-Sized
c. Fu=-Sized
Describe the accident
3. DateofAccident:
Est. Speed:
4. Actions ofpatient’s vehicle:
a. Crossingan intersection
b. Stopped atan intersection
C. Stopped fo「a pedestrian
d. Stopped fort「affic
e. T「avelingat posted speed =mit
f. Travelingfasterthan postedspeed
=mit
g. Turning
5. Howwasthe patient’svehicle:
a. Hitheadon
b. WashitontheIeftf「ont
C. Washitontherightfront
d. Washitontheleftrear
e. washitontherightread
f. Wasrearended
6. Damageto patient’svehicle
a. Compiete
b. Extensive
Todays Date:
C. Minimal
d. Mode「ate
7. Describethe othervehicle
a. Compact
b. Mid-Sized
C. Fu=〃Sized
d. Semitra=er
e. Pick-uPtruCk
8. Damagetotheothervehicle
a. CompIete
b. Extensive
C. Minimal
d. Moderate
9. Weatherconditions
a. CIea「
b. Cioudy
C. Drizz=ng
d. FoggY
e. RainY
f. Sno甲
g. Sto「mY
h. Sumy
lO. Road condition
a. Damp
b. Dry
C. D「vwithicvpatches
d. lcedover
e. Snowedove「
f. Wet
Describe the moment of impact
ll. Body position at momentofimpact
a. Leaningforward
b. SIouchingdowninseat
C. Straight
d. Tu「nedtotheleft
e. Tu「nedtotheright
12. Direction body was thrown
a. Forwardthen backwa「d
b. Backwa「d then forward
c. Totheleft
d. Totheright
e. Aboutthevehicie
f. Outsidethevehide
g. Underthevehicle
13, Head position atimpact
a. Straight
b. T=ted forward
c. Tu「nedtotheleft
d. Tumedtotheright
14. Direction head was thrown
a, Backward then forward
b. Forward then backward
c. Sidetoside
l与. Type of restraint
a. Lapbelt
b. ShouIderbeit
C. ShouIderlapbeit
16. Place patient was seated in vehicle
a. Driver
b. Frontpassenger
c. Back passengerdriversside
d. Back passenge「right side
e. Backpassengermiddie
17. Did ai「bagsdepIoy
a. Yes
b. N0
18. Wereyou seen ata medical fac冊y
fo=owing the accident
a. Yes
b. No
C. 1fsonameoffac冊∨:
Symptoms
l. Dovou havelacerations, CutS Or bruising?
a. Headorface
b. Neck
C. Se∂tbeitb「uising
d. Cuts or bruisesonyourchest
e. Cutsorbruisingonvourarms
f. Cutso「b「uisingonyou「Iegs
2. Head injuries(nowo「atthetimeof
accident)
a. Wereyou knockedoutor
unCOnSC10uS
b. Headaches
C. Facepain
d. Pup=sd碓e「entsizes
e. Dizziness
f. D聞cultywalking
g. BaIanceprobIems
h. Roomspins
i. Disoriented confusion
j. Davdre∂ming
k. Attention problems
上 HearingprobIems
m. Changeinsenseofsme=o「taste
n. D輔cuItyspeaking
O. Memorvproblems
P. Verytiredo「fatigued
q, Appetitechanges
r.∴ Sleep difficuIties
S. Visual disturbances, blu「ryor
double vision
t. Flashbacksto ∂CCident
u. Problemstoreadorwrite
V. Problemsaddingorsubtracting
W. ProbIems Iea「ningnewthings
X. Problems unde「standing
Y. Problems remembering numbers
Z. Problems makingdecisions
aa. Changes in sexua圧unction
bb. Nausea/vomiting
CC. Changes in persona=ty
dd. Wantingto be alone
ee. Mood swings
什. Sadness
gg・ Agitation
hh. Ange「
ii. HelpIessness
jj. Reduce co「甫dence
kk. ApathY
il.面tab冊Y
mm. Sleepiness
nn. Frustration
OO. 1mpatience
3. 」awProbIems
a. 」awpain
b. C=cking
C. PainwhiIechewing
d. Painw帥etaiking
e. Painwhilevawning
f. Painwhilemovingjawfromsideto
Side
4. Neckinju「ies
a. Neck pain, numbness, ting=ng,
Weakness that 「adiates or goes
down in RIGHT shoulder, arm,
forearm, Or hard
b. Neck pain, numbness,ting=ng,
Weakness that radiates or goes
down inしEFT shoulder, arm,
forearm, Or ha「d
C. Neckpain, numbness,ting冊g,
Weakness that 「adiated or goes
down to RIGH丁upper back
d. Neckpain, numbness,tingling,
Weakness that radiated o「 goes
down to LEFT upper back
e. Neck pain thatcauses headaches
f. Neckspasmsorshoulderspasms
g. Popping, C=ckingorclunkingsound
With neck movement
5. Shoulde「injuries
a. ShoulderpainLEFT RIGHT BOTH
b. ShouIder pain with movement
LEFT RIGHT BOTH
C. Shouide「spasmsLEF丁 RiGHT
BO丁H
d. Sharpshoulderpain
e. Dullshoulderpain
f. Achyshoulderpain
g. Pinsand needlesshouIderpain
h. ShouIde「pain that 「adiatesor
Shoots into arm
6. Upperarmpain:しEFT RiGHT BOTH
a. Du=
b. Ache
C・ Sha「p
d. Stabbing
7. Eibowpain:しEFT RIGHT BOTH
a. Du=
b. Ache
C. Sharp
d. Stabbing
8. Fo「ea「m; RIGHTしEFT BOTH
a. Du=
b. Ache
C. Sha「p
d. Stabbing
9. WristPain:RIGHT LEFT BOTH
a. Du=
b. Ache
C. Sha「p
d. Stabbing
lO, Handpain: RIGHT LEFT BOTH
a. Du=
b. Ache
C. Sharp
d. Stabbing
ll. Mid back pain or upperbackpain
a. Du=
b. Ache
C. Sha「p
d. Stabbing
12. Lowe「 back pain
a. Low back pain, numbness, tingIing,
weakness that radiated or goes
down to RIGHT buttock, thigh, leg
O「 f○○t
b. Low back pain, numbness, ting軌g,
Weakness that radiated or goes
down to LEFT buttock, thigh, leg o「
f○○t
C.しOWbackspasms
13. Pelvicorsac「ai pain
a. Pelvic pain, numbness, ting=ng,
weakness that radiated or goes
down to RiGHT buttock, thigh, leg
O「 f°Ot
b. Lowback pain, numbess, ting冊g,
Weakness that radiated or goes
down to LEFT buttock, thigh, leg or
f○○t
C. Sacrai pain(tailbone)
14. Hippain: RiGHT LEFT BOTH
a. Lefthippain
b. Left hip pain, numbness, ting=ng,
Weakness that radiated or goes
down to LEFT buttock, thigh, Ieg or
f○○t
C. Righthippain
d. Right hip pain, numbness, ting=ng,
Weakness that radiated or goes
down to RIGH丁buttock, thigh, leg
O「 f○○t
15. Upperlegpain: RIGHT LEFT BOTH
a. Upperlegpainthatradiatedto
knee
b. Uppe「legspasms
16. Kneepain: RIGHT LEFT BOTH
a. Kneepainthatradiatestocalf
b. Knee pain that radiatesto calfand
ankie
C. Knee pain that radiatesto calf,
ankie and foot
17. Anklepain: RiGHT LEFT BO丁H
a. Ankle pain that radiatestofoot
b. Ankleandfootpain
18. Footpain: RiGHT LEFT BOTH
19. Chest pain
a. Yes
b. N0
20. Stomach pain
a. Yes
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