104 Pike Street Suite 210
Seattle, WA 98101
206.623.2225
Fax: 206.686.7246
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Automobile Accident Questionnaire

Patient's Name:
Today's Date:
Date of Accident:

The following questions pertain to you and the vechile you were in:

Vehicle Type:

Car
Van
Station Wagon
Other
Pickup
Truck
Bus

Vehicle Type:

Subcompact
Compact
Mid-size
Heavy
Full-size
Mini
Light
Other

Your position in the vehicle:

Driver
Passenger/Location
Other
Left
Front Passenger
Middle
Rear Passenger
Right
Third Sear (rear)

Speed of your vehicle:

Stopped
Parked
Slowing
Moving Slowly
Moving Moderately
Moving Fast
Moving at apprx - MPH

Why Vehicle was slowed or stopped:

Traffic Signal
Pedestrian
Stop Sign
Parking
Traffic
Busy Intersection

Collision Type:

Driver Side Impact
Passenger Side Impact
Front Impact
Head On Collision
Rear Impact
Pedestrain Incident

The following questions concern the other vehicle involved in the accident:

Vehicle Type:

Car
Van
Station Wagon
Other
Pickup
Truck
Bus

Vehicle Type:

Subcompact
Compact
Mid-size
Heavy
Full-size
Mini
Light
Other

Conditions at the time of the accident:

Time of day:

Full
Dusk
Night

Road Conditions:

Dry
Damp
Wet
Snow covered
Ice covered
Patchy Ice/Snow

Visibility:

Excellent
Good
Fair
Poor

Visibility compromised by:

Brightness
Darkness
Rain
Snow
Fog
Traffic

The following questions concern the moment of impact of the accident:

Were you...

Totally unaware that the accident was impending
Aware that the accident was impending
Aware that the accident was impending and braced for it

Restraints: (check all that apply)

Seat belt
Shoulder harness
No restraints

If you were the driver of the vehicle, was your foot on the brake pedal?

Yes   No   Knocked off by impact

Was the air bag deployed?

Car not equipped with air bag
Air bag deployed
Air bag not deployed

What position was YOUR headrest in?

High position
Middle position
Low position

Position of YOUR head at time of impact?

Facing straight ahead
Titled forward
Rotated to the left
Rotated to the right

Was your head thrown...?

Backward and then forward
Forward then background
To the left
To the right
To the left then the right
To the right, then the left

Position of Your body at time of impact?

Straight
Titled forward
Rotated to the left
Rotated to the right

Was your head thrown...?

Backward and then forward
Forward then background
To the left
To the right
To the left then the right
To the right, then the left
Across the vehicle
Outside the vehicle
Under the vehicle

Damage to vehicle YOU were in:

Incurred minimal damage
Incurred moderate damage
Incurred severe damage
Was totaled
Not known

Citations:

None issued
Yourself
Driver of vehicle patient was a passenger of
Driver of other vehicle
Not sure

As a result of the force of the collision, which objects in the vehicle did your body strike?

Head

Steering wheel
Dashboard
Windshield
Armrest
Headrest
Rear view mirror
Left door

Left Arm

Right door
Left window
Right window
Console
Gear shift
Front seat
Backseat

Right Arm

Dashboard
Windshield
Armrest
Headrest
Rear view mirror
Left door

Torso

Right door
Left window
Right window
Console
Gear shift
Front seat
Backseat

Left Leg

Steering wheel
Dashboard
Windshield
Armrest
Headrest
Rear view mirror
Left door

Right Leg

Right door
Left window
Right window
Console
Gear shift
Front seat
Backseat

The following questions concern the time period immediately following the accident:

Did you lose consciousness?

Yes
No

Immediately following the accident, did you feel...?

Dizzy
Dazed
Disoriented
Weak
Nervous
Nauseated

Were you able to walk unaided?

Yes
No

Were did you go...?

Drove home
Was driven home
Drove to hospital
Was driven to hospital
Taken to hospital via ambulance
Drove to work
Was friven to work
Drove to school
Was driven to school

Next day discomfort...?

increased   decreased   same

Did your major complaints exist before the accident?

Yes   No

In what areas did you IMMEDIATELY feel pain?

Head
Neck
Upper back
Mid back
Ribs
Chest
Abdomen
Low Back
Pelvis
Shoulder
Left
Right
Arm
Left
Right
Elbow
Left
Right
Wrist
Left
Right
Hand
Left
Right
Fingers
Left
Right
Buttock
Left
Right
Hip
Left
Right
Thigh
Left
Right
Knee
Left
Right
Calf
Left
Right
Ankle
Left
Right
Foot
Left
Right
Toes
Left
Right

In what aread did you experience lacerations (cuts)?

Head
Neck
Upper back
Mid back
Ribs
Chest
Abdomen
Low Back
Pelvis
Shoulder
Left
Right
Arm
Left
Right
Elbow
Left
Right
Wrist
Left
Right
Hand
Left
Right
Fingers
Left
Right
Buttock
Left
Right
Hip
Left
Right
Thigh
Left
Right
Knee
Left
Right
Calf
Left
Right
Ankle
Left
Right
Foot
Left
Right
Toes
Left
Right

At the hospital, what areas were x-rayed?

Head
Neck
Upper back
Mid back
Ribs
Chest
Abdomen
Low Back
Pelvis
Shoulder
Left
Right
Arm
Left
Right
Elbow
Left
Right
Wrist
Left
Right
Hand
Left
Right
Fingers
Left
Right
Buttock
Left
Right
Hip
Left
Right
Thigh
Left
Right
Knee
Left
Right
Calf
Left
Right
Ankle
Left
Right
Foot
Left
Right
Toes
Left
Right

Where did you experience pain on the day FOLLOWING the accident?

Head
Neck
Upper back
Mid back
Ribs
Chest
Abdomen
Low Back
Pelvis
Shoulder
Left
Right
Arm
Left
Right
Elbow
Left
Right
Wrist
Left
Right
Hand
Left
Right
Fingers
Left
Right
Buttock
Left
Right
Hip
Left
Right
Thigh
Left
Right
Knee
Left
Right
Calf
Left
Right
Ankle
Left
Right
Foot
Left
Right
Toes
Left
Right

Devine Chiropractic & Rehab Center

About You

Name Preferred Name Address City State Zip Home Phone Cell Phone Other Birthdate Age Gender (Check One) Female Male Prefer Not to Answer SSN# Email Occupation Employer
Status (Check One) Minor Single Married Divorced Separated Widowed Spouse/Partner?s Name Emergency Contact Name Relation Home Phone Cell Phone How Did You Hear About Our Office?

Reason for Visit

Is your condition a result of: Work Auto Accident Trauma Chronic Other

Briefly describe what happened When did this condition begin? Is it getting better or worse?
Have you had a similar condition in the past? Yes No
Have you seen any other doctors for this condition? Yes No
If Yes, whom?
Have you ever had chiropractic care before? Yes No
If Yes, whom?

Health History

Please list any surgeries/hospitalizations that you have had and the dates:
Please list serious past injuries and the dates:
Please list all serious medical condition/allergies that you have or ever had:
Please list all family members with major medical conditions:
Are you taking any of the following medications? Nerve Pills Pain Killers Muscle Relaxers Insulin Blood Thinners Tranquilizers Others
Do you take: Vitamins Supplements   Do you exercise? Yes No. If yes, how much?
Are you wearing: Heel Lifts Sole Lifts Orthotics Arch Support

Do you smoke? Yes No. If yes, how much? How long?
For women: Are you pregnant? Yes No.   Do you take birth control? Yes No.

When was your last cycle?

Do you currently have or ever had any of the follow diseases or conditions?

Yes No     Heart Attack/Stroke
Yes No     Heart Surgery/Pacemaker
Yes No     Heart Murmur
Yes No     Congenital Heart Defect
Yes No     Mitral Valve Prolapse
Yes No     Artificial Valves
Yes No     Drug/Alcohol Abuse
Yes No     Hepatitis
Yes No     HIV/AIDS
Yes No     Shingles
Yes No     Cancer/Chemotherapy
Yes No     Emphysema/Glaucoma
Yes No    Anemia
Yes No    High/Low Blood Pressure
Yes No    Psychiatric Problems
Yes No    Ulcers/Colitis
Yes No    Fainting/Seizures/Epilepsy
Yes No    Sinus Problems
Yes No    Asthma
Yes No    Diabetes/Tuberculosis
Yes No    Difficulty Breathing
Yes No    Arthritis
Yes No    Low Back Pain
Yes No    Neck Pain
Yes No    Migraine/Headaches

Please diagram your problem areas above using the symbols below and rate the intensity of the pain on a scale of 1-10. A 10 represents the worst pain imaginable. Circle all areas of pain that do not fit the descriptions below.

B = Burning
S = Stabbing/Sharp
N = Numbness/Tingles
T = Tightness
A = Aching

New Patient Promise

Our promise is based on the simple truth that if we satisfy and care for our patients, they will get well faster and be more likely to share their chiropractic experience with others.

Since chiropractic results vary, we can?t guarantee results, but we can promise your satisfaction. So, within seven days of beginning care, if you are not completely satisfied with your decision to begin chiropractic care, we will gladly refund the money you have paid us. Since most spinal problems involve muscles and soft tissue that are slow to heal, continued chiropractic care is often required for maximum improvement.

Office Policies

A clear definition of our policy allows us to concentrate on restoring and maintaining your health. We are always happy to answer any questions that you may have regarding our policy, your account, or your insurance coverage. Insurance Information

Health and accident insurance policies are an agreement between the insurance carrier and you. We will gladly prepare any necessary reports and forms to assist you in filing claims with your insurance company. Any amount authorized to be paid directly to Devine Chiropractic & Rehab Center, P.S. will be credited to your account upon receipt.

All services rendered to you are charged directly to you and you are personally responsible for payment. In order to facilitate the correct and rapid processing of your insurance claim, you can do the following: Call your insurance agent to determine exactly what coverage you have. Ask what deductible, if any, applies to your policy, and how much of your claim your insurance company will pay. If you have any questions, feel free to ask. Our staff is experienced in insurance claim handling and will be glad to assist in any way they can.

1. If you have been in an auto accident or have been hurt on the job, we suggest that you discuss your coverage with our insurance office. We may have suggestions that will help you in this regard.

2. You will be asked to authorize Devine Chiropractic & Rehab Center, P.S. to furnish information regarding your case directly to your insurance company and to assign all benefits as a result of the claim. This will expedite its handling.

Patient Payment Schedule

Our patients? health needs are paramount. Patients are allowed to receive the care they need and reduce the balance on a monthly schedule rather than paying for visits as they are received. Monthly payments are required on all unpaid balances.

Appointment Policy

Please notify our office if you are unable to keep your schedule appointment. You will not be charged for missed chiropractic appointments. Should you need to cancel or reschedule a massage appointment, we require at least 24 hours? notice. Missed massage appointments without 24 hours? notice will be charged unless that time can be filled by another patient.

Referral Policy

If you move from our area, we will be glad to refer you to another chiropractor. We will forward your x-rays and records after you sign a release transfer.

Discharge Policy

If you terminate your care at Devine Chiropractic & Rehab Center before your doctor feels your condition has stabilized, any fees for professional services will be immediately due and payable, unless prior arrangements have been made.

Other uses of medical information: We will ask for your written authorization before using or disclosing medical information about you in any other situation not covered by this notice. If you choose to authorize use or disclosure you can later revoke that authorization by notifying us in writing.

Your rights regarding personal medical information: In most cases you have the right to look at or get a copy of medical information that we use to make decisions about your care after submitting a written request. We may charge a fee for the cost of copying, mailing, or related supplies. If we deny your request to review or obtain a copy of your medical record, you may then submit a written request for a review of that decision.

  • If you think that information in your record is incomplete or incorrect you have the right to request that we correct the records by submitting a written request. We would deny the request when the information was not created by us, not part of the information maintained by us, or if the record was accurate. You may appeal in writing, a decision not to amend your record.
  • You have the right to a listing of those instances where we have disclosed medical information about you, other than for treatment, payment, or health care operations or where you specifically authorize the disclosure. You must submit a written request stating the time period desired for the accounting, which must be less than a six-month period. The first disclosure list in a 12-month period is free.
  • You have a right to a paper copy of this notice.
  • You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing.

  • You may request in writing that we do not use or disclose your medical information for treatment, payment, or health care operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency.
  • We are not legally required to accept you request, but will consider it and inform you of our decision. All written requests or appeals should be submitted to Dr. James A. Devine.

    Complaints:

    If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact Dr. James A. Devine at 104 pike St Suite 210, Seattle, WA 98101.

  • Finally, you may send a written complaint to the U.S Department of Human Services Office Civil Rights. We will happy to provide the address.
  • Under no circumstance will you be retaliated against of penalized in any way.
  • I hereby authorize the Doctor to treat my conditions as he or she deems appropriate. It is understood and agreed that the amount paid the Doctor, for x-rays, is for the examination only and the x-ray negatives will remain the property of this 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.

    Acknowledgement:

    By signing my name below, I acknowledge receipt of a copy of this notice, and my understanding and agreement to its terms.

    Printed Name
    Signature     Date
    Consent to Treat Minor     Date
    Guardian Signature Authorizing Care     Date

    Notice of Privacy Practice

    This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

    The information privacy practices in this notice will be followed by:

  • Any health care professional that treats you in our office.
  • All departments and units including the Billing Department.
  • All full, part time, or contractual employees, including students affiliating with any of our clinics.
  • Any business associate or partner of Devine Chiropractic & Rehab Center, P.S. with whom we share health information.
  • Our pledge to you: We value you as a patient and appreciate the opportunity to serve you. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. By law, we are required to:

  • Keep medical information about you private.
  • Give you this notice or our legal duties and privacy practices.
  • Follow the terms of the notice that is currently in effect.
  • Changes to this notice: We may change our policies at any time. Changes will apply to medical information we already hold and to the future information after the change occurs. Before we make significant change to our policies, we will alter our notice and post the new notice for public view in our office. You can receive a copy of the notice at any time. You will also be asked to acknowledge in writing your receipt of this notice.

    How we may use and disclose your personal medical information: We may use and disclose medical information about you for any purpose regarding your treatment, to obtain payment for treatment (such as sending billing information to your insurance company or Medicare), and for health care operations (such as comparing practice patterns to improve treatment methods).

  • We may use and disclose medical information about you without your prior authorization for several other reasons, subject to certain requirements: for public health purposes, abuse or neglect reporting, health oversight audits or inspections, research studies, workers? compensation purposes, and emergencies. We also disclose medical information when required by law (such as in response to valid judicial or administrative orders).
  • We also may contact you for appointments reminders, or to tell you about or recommend possible treatment options, alternatives, health related benefits, or durable medical goods that may be of interest to you.
  • We may disclose medical information about you to a friend or family member who is involved with your medical care.
  • Accepted by (Print Name):   Date
    Signature:

    Informed Consent

    I understand that my doctor?s recommendations are paramount for my optimum health and the improvement of my condition. Failure to follow my doctor?s recommendations may hinder or prolong my recovery and increase the number of visits required to correct my problem.

    I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures including, but not limited to, diagnostic x-rays on me (or the patient named below, for whom I am legally responsible) by any licensed doctor of chiropractic who treats me at Devine Chiropractic & Rehab, P.S.

    I have had the opportunity to discuss with my doctor at Devine Chiropractic & Rehab Center, P.S. and/or other office personnel the nature and purpose of chiropractic adjustments and other procedures.

    I understand an am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including, but not limited to fractures, disc injuries, strokes, dislocations, and sprains. I do not expect the doctor to be able to anticipate and explain all of the risks and complications of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interest.

    To Be Completed by Patient

    Patient Name:
    Signature:
    Date Signed
    Witness to Patient?s Signature:

    If Patient is a Minor, Physically, or Legally Incapacitated to be completed by Patient?s Representative

    Patient?s Name:
    Name of Representative:
    Date Signed
    Signature of Representative:
    Relationship of Authority of Patient?s Representative:

    PERSONAL INJURY BILLING INFORMATION

    Name   Date
    Date of Injury
    Do you have Personal Injury Protection? Yes   No   I DON?T KNOW

    Have you opened a claim with your insurance company? Yes   No

    Auto Ins. Comp.
    Policy #: Insurance Co. Phone #
    Claims Ins. Co. Address
    Claims Adjuster Claim #
    Do you have an attorney? Yes   No

    Please fill in information below if your answer is yes


    Attorney?s Name Phone
    Attorney?s Address
    Other Driver?s Name
    Ins. Comp. Phone
    Policy # Claim #

    All of the above information is correct to the best of my knowledge. I agree that Devine Chiropractic will bill my insurance company, however, I also agree that any balance owing is ultimately my responsibility.

    Signature Date

    Payment Plans for Chiropractic and Massage

    To All New Patients: Please initial next to your method of payment

    Insurance Patient: Our office provides a courtesy verification of your benefits with your insurance information. This is through our third party medical billers which will give us benefit information within 24 hours. We recommend that you call your insurance company to verify that they will cover our in-network doctor, Dr. James Devine, along with x-rays. We recommend that you should know the details of your insurance (and if a deductible or co-pay applies). We will bill your insurance as a courtesy to you, with the understanding that you are ultimately responsible for your account in our office. All co-pays are expected at the time of your service. If you do not know what your copay is, you will be required to pay $25 per visit until the correct amount of your co-pay has been determined.

    Personal Injury Patient: It is your responsibility to provide our office with all insurance information; including PIP, third party, health insurance, etc. We need all claim numbers, adjuster/manager contact information, and insured person?s name, address, and phone numbers. You are responsible for payment to our office for any services rendered.

    Labor & Industries Patient: You are responsible for filling out Labor & Industries long form or the form for self-insured L&I. You are also to have an accident report filed with your employer. If your claim is not accepted, you will be responsible for your account balance.

    Cash / Private Pay Patient: To receive our discounted rate, payment is required at the time services are rendered. We accept all forms of payment (Cash, Personal Checks, Visa, MasterCard, American Express).

    **I understand that any missed massage appointments without 24 hour notice will incur a $40 fee.

    ** understand that future appointments will not be scheduled until the missed appointment fee has been paid.

    Date:
    Patient Signature:

    Dr. James Devine, DC
    Dr. Sarah Flood, DC
    Dr. Ben Greenwade, DC
    Dr. James Barthelme, DC