sw.91.2019 CONFIDENTIAL PATIENT INTAKE FORM Today’s Date ‘Your Name: First, Last ML Your Attorney; —Your Attorney's Phone#t:( Date of Accident: Date of Birth: Your Age. Gender: OM OF SSH: HIATT TT) vourteight: Your Weigh Your Address: Street: Apt: ci State: Zip: Your e-mail address: Cell Phat ( ) Home Ph # ( ) Work Ph # ( ) In case of emergency, contact: Name. Relationship to you. Phone #:( ) _ Address: _ ‘Are you Right or Lefthanded? Right Left Do you have a job? G_NotEmployed Employed —_O Self-Employed Position: Employer: ‘Are You a Student? QNo Yes ‘Are You Retired? QNo OYes Family Status: Q Married 1 Single QDivorced O Separated Q Widowed 1 Single Parent ‘Number of dependents you support (not including yoursel): POST- ACCIDENT INFORMATION (FOR ALL ACCIDENTS) Atthe scene, there was: Police. Fire Department Ambulance ONA Complaints: 1. Are you able to perform work duties? No i Yes © Yes, but wth imitations Do not work Ci Lost job because ofthis accident 2, Are there limitations in performing (check all that apply: C1 Domestic dutles C1 Sports G1 Hobbies 3, Do you have to pay for household assistance because of this accident? QNo Yes. 4. Are you having relationship probloms because of this accident? No ayes | Yes, please specify with whom: Q Spouse 1 Family Friends Coworkers MEDICAL TREATMENT RELATED TO THIS ACCIDENT: Did you have treatment related to this accident prior to today’s visit: Yes No If Yes, + When did you go for care? Q Right after the accident Q Several hours later Cl Next day Q Other * Where did you go for care (lst all that applies)? A. Hospital's Name Date(s) of visit ‘+ Were you taken by ambulance Yes No Urgent Care, Name Date(s) of visit B. ©. Doctor's Office, Name Date(s) of visit D. Another Physical Therapy Office, Name. Date(s) of visitw01.2019 Did you have any tests done because of this accident? LI Yes No, if yes, check all that applies (see below): O X-ray QMRIOCT-Scan O Ultrasound O Other pe C. Were you given a disability certificate? No Yes ifYes: from: D. Did you attemptto treat yourself? ~—-«sGANo Yes If Yes, Medicine/Treatment (Specify): GHeatiCold O Exercises Oi Bed rest U1 Pain medication Oi Other (Specify): E. Do you have any visible injuries (bruises, lacerations, etc.) because of this accident? Q Yes Q No Ifyes, what part of the body: CAR ACCIDENTS ONL} Do you or any member of your household own acar? Q Yes No ‘The vehicle you were in: GQ Your own 1 Rented i Parent's O Other In what state did your accident occur? |Inwhich state is your car insured Name of Driver: Policy holder’s name. Insurance Company name: a Policy #: Claim #: Adjuster's Name: Adjuster's Phone #:( DoYouHavePIP? Yes CINo If Yes: PIP Amount @ 2,500 015,000 27,500 O Other amount Do You Have Med Pay? Yes CINoIf Yes: Med Pay Amount Q 2,500 15,000 17,600 1 Other amount ‘Are you a Virginia policy holder? No Yes if Yes: number of vehicles on your policy: Were you the: Driver Passenger, ifso: Ol Rear-seated 0 Front-seated Accident happened when your car was: Moving Stopped O Parked You were ina: (Car QSUV Van U1 Pick-up Truck C1Taxi Q Uber/Lyft Oi Company Car Your vehicle was: Q Hit by another Qi Collided with another Q Rear-ended Other. Upon impact, did your vehicle hit anything else? No Yes Ifyes, please specify below. Pole AWall ACurb OTree CAnother car Other Upon collision, your body: OI Moved backward and forward Moved forward and backward O Twisted around Was thrown from side to side ther Were you Seat-belted? O1No Yes If Yes, did you sustain injuries from seatbelt? QNo © Yes Was your car towed? No Yes Did your airbags deploy? QNo Yes Briefly describe how the accident happened: INFORMATION ABOUT THE OTHER CAR THAT HIT YOU: ‘Type of the vehicle: Car Q. SUV O Pick-up Truck Van O Bus O Taxi O Motorcycle Q Other. Driver's Name ___Name of Insured Auto Insurance Policy #: ‘The other car License Plate: Which State? MTA-BUS ACCIDENT:Do you or any member of your household own acar? Q Yes CNoif Yes: Policy holder's name Insurance Company name: Policy #t Claim #: Adjusters Name: Adjuster’s Phone #( 9) DoYouHavePIP? Yes CINoIf Yes: PIP Amount O 2,600 15,000 17,500 © Other amount DoYou Have Med Pay? Yes CINoIfYes: Med Pay Amount 2,500 15,000 117,500 © Other amount Atthe moment ofthis accident, you were: Sitting Q Standing The bus you were in was: C1HItby another vehicle Hit another vehicle other Upon colision, yourbody: C1 Moved forward and backward Twisted around © Wes throw from side to side Upon impact, you: \Felldown C1Hitapole CQ Hita fellow passenger ClHitawindow C Hit the seat infront PEDESTRIAN, MOTORCYCLE, SCOOTER, BICYCLE ACCIDENT: Do you or any member of your household own a car? Q Yes CNo if Yes: Policy holder's name Insurance Company name: Policy #: Claim i: Adjuster's Name: Adjuster’s Phone #:( DoYouHave PIP? Ci Yes CINo If Yes: PIP Amount C1 2,500 6,000 017,00 © Other amount Do You Have Med Pay? U1 Yes CINo If Yes: Med Pay Amount 2,500 (15,000 07,500 2 Other amount YouWere: O Pedestrian Bicyclist_ © Scooter Motorcyclist. Other. At the time ofthis accident you were on the: O Street 1 Sidewalk 1 Other _ Atthe time ofthis accident, you were: Moving C1 Parked Standing on the street C1 Crossing the streot Upon collision, your body hit’ OThe ground QApole QAwall Dother ‘What type of car hit you? GCar Q.Truck OlVen OBus G SUV O Taxi O Motorcycle O Other Wore you wearing ahelmet? No @ Yes Did you hit your head? No OYes WORKERS COMPENSATION AND PERSONAL INJURY: This Accident Happened: C1 At Work: WC Insurance Company: ee Claim #: ‘Adjuster's Name: ‘Adjuster’s Phone No: This Accident Happened: CLAtHome On the Street Gina Store Cother Did you: Slip Fat! O other Have you worked since this accident? No Yes Last day worked Brietly Describe How the Accident Happened: Would you lke to be treated at the current location? Yes No HF No": | would like to be transferred to the following location: © Facknowledge the receipt ofthe Note to Our Patients, List of Locations and HIPAA Notice of Privacy Practices, Signature of Patient (Parent or Guardian for MinoriSpecity retationship) 1 Office Representative DC SignatureDr. Diego Proano, De Chiropractor Oinical Director € iran enmorenene ) ALT SHORES Vitality Chiropractic and Medical Wellness Consent for Examination {hereby authorize vitality Chiropractic and Medical Wellness and its licensed doctors and assistants, based on ‘my complaints and the history | have provided, to undertake an examination and provide an evaluation and treatment plan which may include chiropractic adjustments and other tests and procedures considered ‘therapeutically appropriate. | also wish to rely on the practice doctors to make these decisions about my care, ‘based on the facts then known, that they believe are in my best lerest. Insurance Assignment of Benefits | assign payment by my insurance company directly to Vitality Chiropractic and Medical Wellness. | understand that! am financially responsible for charges and copayments not covered by my insurance carrie. n the unfortunate event collection procedures are required to collect an outstanding balance, the patient shall be "responsible forall reasonable cost ofa collection agency, attorney, and/or court costs, Release of Information | authorize the use and disclosure of heath information that pertains to me for treatment, payment, or official ‘operations. | understand that information disclosed pursuant to this authorization may be re-disclosed to additional parties and no longer protected. In addition, | authorize Vitality Chiropractic and Medical Wellness to share findings/send reports to my family physician or other health care provider ised on my health history form. "understand that | may revoke this authorization at any time by signing the revocation of my copy of this form ‘and returning it to Vitality Chiropractic and Medical Wellness. | further understand that any such revocation, ‘does not apply to the extent that persons authorized to use to disclose my health information have already acted in reliance on this authorization. | understand this authorization will automatically expire atthe end of my treatment cycle. ! understand that | have the right to inspect and obtain a copy of any information disclosed pursuant to this authorization, 1 lunderstand that Vitality Chiropractic and Medical Wellness will receive compensation forthe uses and disclosures that | have authorized. | authorize Vitality Chiropractic and Medical Wellness to leave any messages necessary at my home/work in "regards to any appointments, billing, or insurance issues that may occur. Patient Printed Name Patient Signature Date £101 Executive Boulevard Suite 280_+ Rockville, MD. 20852 « (301)231-0050_www.rockvillevitalty.com We specialize in treatments including: ‘Chiropractic Physical Therapy Dry Needling Exercise RehabilitationDr. Diego Proano, Dc. Oriropractor Ginical Director A rrasire cyamornacne Vitality Chiropractic and Medical Wellness Providing comprehensive health care since 1982 Wellness will receive compensation for the uses and disclosures that | have authorized. {authorize Vitality Chiropractic and Medical Wellness to leave any messages necessary at my home/work in regards to any appointments, billing, or insurance issues that may occur. ee Patient Signature (Patient or Legal Representative for Patient) Printed Name Date eS Legal Representative’s Relationship to Patient +6101 Executive Blvd Suite 280. Rockville, MD 20852 __« (301)231-0050 www.rockillevitality.com We specialize in treatments including: ‘Chiropractic Physical Therapy “Dry Needling Exercise RehabilitationDr. Diego Proano, Dc, Chiropractor Owner nical Director $ Acnsiry cuporracnc ALTLASHURGERAS Vitality Chiropractic and Medical Wellness Providing comprehensive health care since 1982 Consent for Treatment The nature and purpose ofthe chiropractic examination and evaluation, the chiropractic adjustments and the other procedures that may be recommended during the course of my care have been explained and deserbed {p.m salstaction, Based on current ndings, practice doctors have discussed my diagnosis and treatment plo, ‘he benefits and expected improvement withthe proposed treatment and the reasonable alternatives tothe Proposed treatment. The doctors have answered my questions regarcing the planned treatment and course of care that | will receive, {have also been advsed that although the incidence of complications associated with chiropractic services Is cutremely Fare, anyone undergoing adjusting or manipulative procedures should know that rare possible hazard and complications that may be encountered or result during the course of care. These include but are not limited to fractures, disc injuries, strokes, dislocations, sprains and those which relate to physical aberrations unknown or undetectable by the doctor. understand and accept that: 1-| have the right to withdraw from or discontinue treatment at any time and that the practice doctors wl Advise me of any material risks in the regard. 2-That nether the practice of chiropractic nor medicine isan exact sclence and that my care may involve the ‘making of judgments based on the facts known to the doctor during my course of care. 2 That snot reasonable to expect the doctor to beable to anticipate or explain al risks and complications, or an undesirable result does not necessarily indicate any error in judgment or treatment. In addition, there is no guarantee as to results with respect to any course of care or treatment, {have ead this consent and have had an opportunity to ask questions about the consent and understand the care and treatment | may receive. My signature below acknowledges my consent to evaluation and treatment by the practice. ee Patient Printed Name Patient Signature Date Doctor Printed Name. Doctor Signature Date 26101 Executive Blvd Suite 280 + Rockville, MD 20852_» (301)231-0050 www.rockvillevitality.com We specialize in treatments includini ‘Chiropractic Physical Therapy »Dry Needling ‘Exercise Rehabilitation