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