CFPC-LA - Patient Intake Form

Patient Information

Patient First Name

Last Name

Date of Birth

Gender

Male Female Other

Height

ft inches

Weight

lbs

Blood Pressure

Date of Accident

Time of Accident

Pain Information

Type of Pain:

Throbbing Stabbing Dull Aching Pinching Steady

Persistence of Pain

Chronic (Persistent) Acute (In the moment)

Do you feel any

Radiation

Numbness

Tingling

Did pain develop right away?

No Yes

If no, when did the pain start?

Type of Accident

Auto Accident Slip and Fall Work Injury Motorcyclist Pedestrian Bicyclist

Other PI:

Vehicle Information

Vehicle Damage Location

Mark on the vehicle where the car was damaged by tapping on the diagram:

Selected Damage Areas:

No areas selected

Accident Details

Did you start having headache, dizziness, vomiting after the accident?

Headache Dizziness Vomiting

Did you start having anxiety or depression?

Anxiety Depression

Trouble sleeping?

No Yes

How many people were in your vehicle?

Property Damage of your Vehicle

$

Total Loss Not Sure

Which city and what street did the accident occur in?

Type of Vehicle patient was driving (Make/Model/Year) VS other Party Vehicle

How did the accident occur?

Medical Information

Imaging None

X-Ray

Body part:

MRI

Body part:

CT Scan

Body part:

Other Imaging

Current Medications None

Medication:

Currently taking any blood thinners?

(Warfarin, Heparin, Apixaban, Rivaroxaban, Dabigatran etc)

No

Yes

Allergies (medications, animals, food) None

Penicillin

Iodine

Keflex

Aspirin

Codeine

Latex

Valium

Demerol

Erythromycin

Other:

Past Medical History

None

Past Surgical History

None

Any Anesthesia Complications?

No

Yes

For Women ONLY

Have any kids?

No

Yes

If yes, how many?

C Section - How Many?

Natural Birth - How Many?

Previous Accidents

Been involved in any other accidents?

No

Yes

Previous Accident #1

When?

What type of accident?

Description:

Habits

Smoking

Non-Smoker

Smokes

How many cigarettes or packs per day?

Alcohol

No Alcohol

Occasional

Regularly

Bottles per day:

Family History

Any health problems in the patient's family

None

Family Member:

Mother

Father

Brother

Sister

Other

Type of problem:

Type of Treatment

Current Treatment

Chiropractic Therapy

Duration:

Did it help?

No

Yes

If yes, please explain:

Acupuncture

Duration:

Did it help?

No

Yes

If yes, please explain:

Physical Therapy

Duration:

Did it help?

No

Yes

If yes, please explain:

Other Physicians

Did the patient see any other physician for this accident?

No

Yes

Orthopedic Surgeon

Pain Management

Neurologist

Psychiatrist

Other:

Chronic Pain History

Did the patient have CHRONIC PAIN before your accident or injury?

No

Yes

If Yes, Please explain (Ex: chronic back pain, chronic neck pain, chronic knee pain etc.):