PATIENT PAIN DRAWING Name/Nombre _______________________________________________________________________________________________ Using the symbols given below, mark ALL the areas on your body where you feel the described sensations. Include all affected areas. ACHING Dolorido ▲▲▲

NUMBNESS Entumesido ■■■

PINS & NEEDLES Alfileres y Agujas ○○○

Date / Fecha ____/____/____

Abajo hay dos figures del cuerpo con vistas de frente y de atrás. Por favor indique TODAS las partes del cuerpo en donde siente Ud. Los dolores y sensaciones. Use los símbolas indicados. BURNING Ardores xxx

STABBING Puñaladas ///

OTHER Otro ●●●

Pain in arm(s) compared with neck. / Dolor en el brazo(s) comparado con el cuello: … Worse than / Peor … Same as / Igual … Less than / Menos

Pain In leg(s) compared with back. / Dolor en la pierna(s) comparado con la espalda: … Worse than / Peor … Same as / Igual … Less than / Menos

Date of birth / Fecha de nacimiento: ____/____/____ Referred by / Referido: ______________________________________________________________________________ Are you presently working? / Está trabajando en el presente? … Yes/Sí … No Employer / Nombre del Empleador: _______________________________________________________________________________________________________________ Occupation / .Ocupación: _______________________________________________________________________________________________________________________ Patient Signature / Firma del Paciente: (X) __________________________________________________________________________________________________________ Judd Chiropractic Inc. 532 Redondo Ave. Long Beach, CA 90814, Forms – Patient Pain Drawing.doc

(562) 439-0419, (714) 892-3131 Revised: 01/01/05

MEDICAL HEALTH QUESTIONNAIRE English/Spanish PERSONAL INFORMATION Date: _____/_____/_____ Name/Nombre: _______________________________________________________________

Age/Edad: _____

Birth Date/Fecha de Nacimiento:

_____/_____/_____

Address/Dirección: ____________________________________________________________________________

Birthplace/Lugar de Nacimiento: _________________

Telephone/Telefono: (_____)-_____-_______

Referred by/Recomendado Por: __________________

Occupation/Ocupación: ________________________________________________________________________________________________________________________ hours you work/cuantas horas trabaja: _____

# of years/cuantas años: _____

PAST RELEVANT MEDICAL HISTORY/ Historia Médico Injuries and Accidents: (office use only) wc/pi pg 4 Surgeries/ Historia de Intervención Quirúrgica Have you ever been in a hospital? / Ha estado hospitalizado alguna vez?

… Yes(Sí)/… No

Describe hospitalizations. (include surgeries, if any- type of surgery, dates, hospitals & doctors names) Describa sus hospitalizaciones (incluya operaciones, si ha tenidotipo de operación, nombres de hospitales y de médicos) 1.

_________________________________________Date _____/_____/_____ Doctor/Hospital__________________________

2.

_________________________________________Date _____/_____/_____ Doctor/Hospital__________________________

3.

_________________________________________Date _____/_____/_____ Doctor/Hospital__________________________

Have you ever been treated for: / Ha estado alguna vez bajo tratamiento debido a: … Mental Illness? / Enfermedades mentales?

… Fractures? / Fracturas?

… Head Injury? / Heridas en la cabeza?

Allergies/Alergias: _________________What Kind?/Cuáles? ___________________________________________________________________________________________ Medications: You Are Taking? Medicamentos que toma usted _________________________________________________________________________________________ Illnesses: Have you had? (Check) /Ha padecido de: (Marque) … Measles/Sarampión

… Mumps/Paperas

… Whooping Cough/Tos Ferina

… Chicken Pox/Varicela

… Scarlet Fever/Fiebre escarlatina

… Diptheria/Difteria

… Rheumatic Fever/Fiebre Reumática

… Diabetes Mellitus/Diabetes Melitis

… Poliomyelitis/Poliomelitis

… Tuberculosis/Tuberculosis

… Hepatitis/Hepatitis

Any other illnesses? / Ha padecido de otras enfermedades?___________________________________________________________________________________________ SYSTEMS HISTORY/ Historia de organismo Directions: / Instrucciones:

Check Yes or No to each question below. Marque sí o no a cada pregunta abajo.

EYES, EARS, NOSE, THROAT/ OJOS, OIDOS, NARIZ, GARGANTA Are you hard of hearing? Do you have constant noises in your ears? Have you at times had bad nose bleeds? Do your eyes continually blink or water? Do you often see spots before your eyes? Is your vision poor? Do you often have pain in your eyes? Do you suffer from frequent sore throats? Do you suffer from frequent earaches? Do you have ringing in the ears? Have you ever had a goiter, or thyroid disease?

… Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No

Judd Chiropractic Inc. 532 Redondo Ave. Long Beach, CA 90814, Forms – Medical Health Questionnaire.doc

¿Tiene usted difficultad para oír? ¿Oye sonidos constantes en sus oídos? ¿Ha tenido alguna vez hemorragias nasales de seriedad? ¿Le parpadean o lloran los ojos continuamente? ¿Ve Ud. manchas delante de los ojos a menudo? ¿Tiene Ud. mala vista? ¿Sufre Ud. de dolor en los ojos a menudo? ¿Le dan dolores de garganta con frecuencia? ¿Le dan dolores de oído con frecuencia? ¿Le zumban los oídos? ¿Alguna vez ha tenido bocio o alguna enfermedad de la glándula tiroide? (562) 439-0419, (714) 892-3131 Revised: 01/01/05

RESPIRATORY/RESPIRATORIO Do you frequently suffer from heavy chest colds? Do you suffer from asthma? Are you troubled by constant coughing? Have you ever coughed up blood? Have you ever had TB (tuberculosis)? Have you ever had a chronic chest condition? Do you often have pain in your chest when taking deep breaths?

… Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No

¿Sufre Ud. Frecuentemente de resfrio del pecho? ¿Sufre de asma? ¿Tiene tos constante? ¿Ha escupido sangre alguna vez? ¿Ha padecido de tuberculosis? ¿Ha tenido alguna enfermedad crónica del pecho? ¿A menudo le dan dolores en el pecho cuando respira profundamente?

CARDIOVASCULAR/CARDIOVASCULAR Have you ever been told you had heart trouble? Do you have pains in the heart or chest? Does exercise or excitement cause you to have pains in the chest? Are you often bothered by thumping of the heart? Has a doctor ever said your blood pressure was too low? Has a doctor ever said your blood pressure was too high? Do you often have difficulty breathing? Do you often have to stop for breath when walking up stairs? Have you ever had to sit up to catch your breath? Are your ankles often badly swollen? Has a doctor ever said you had varicose veins?

… Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No

¿Le han dicho que sufre del corazón? ¿Siente dolor en el corazón o en el pecho? ¿Cuando hace ejercicio o se emociona, le dan dolores al pecho? ¿Le dan palpitaciones al corazón a menudo? ¿Algún médico le ha dicho que sufre de presión arteria baja? ¿Algún médico le ha dicho que sufre de presión arterial alta? ¿Tiene frecuentemente dificultad para respirar? ¿Cuando sube escaleras, tiene que pararse a menudo para poder respirar? ¿Alguna vez ha tenido que sentarse para poder respirar? ¿Se le hinchan mucho los tobillos? ¿Algún médico le ha dicho que sufre de varices?

GASTROINTESTINAL/GASTROINTESTINAL Have you had an unexplained loss of weight? Is your appetite always poor? Do you usually belch a lot? Do you usually pass a lot of gas by rectum? Do you suffer from indigestion? Do you suffer from frequent loose bowel movements (diarrhea)? Are you constantly constipated? Do you frequently have severe stomach pains? Do you have frequent vomiting? Have you ever vomited blood? Have you ever passed blood with your bowel movement?

… Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No

¿Ha tenido pérdida de peso que no se pueda explicar? ¿Generalmente sufre de falta de apetito? ¿Eructa Ud. mucho? ¿Generalmente pasa mucho gas por el rector? ¿Sufre de indigestión? ¿Le di soltura del estómago (diarrea) menudo? ¿Está Ud. constantemente estrenido? ¿La dan dolores de estómago frecuentemente? ¿Vomita mucho? ¿Alguna vez ha vomitado sangre? ¿Alguna vez ha pasado sangre con el excremento?

GENITOURINARY/GENITO-URINARIO Do you often urinate frequently? Do you have trouble holding your urine? Have you ever dribbled urine when sneezing? Have you ever had blood or gravel in your urine? Do you often get up at night to urinate? How many times do you get up? Do you often have pain or burning on urination? Have you ever had a kidney disease? Do you have trouble starting your stream when urinate? Are sexual relations painful or difficult for you? Have you had a recent loss of interest in sexual relations?

… Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No ____x per night … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No

¿Orina con frequencia? ¿Le cuesta trabajo contener la orina? ¿Alguna vez ha goteado orina mientras estornuda? ¿Alguna vez ha tenido sangre o arenilla en la orina? ¿Se levanta a menudo de noche para orinar? ¿Cuántas veces se levanta? ¿A menudo le da dolor o ardor cuando orina? ¿Ha tenido alguna enfermedad de los rinones? ¿Le cuesta trabajo comenzar a orinar? ¿Le son dolorosas o difíciles las relaciones sexuales? ¿Ha perdido el interes en las relaciones sexuales recientemente?

SKIN AND EXTREMITIES/LA PIEL Y LAS EXTREMIDADES Have you had arthritis or rheumatism? Are your joints often painfully swollen? Do you frequently get severe leg cramps when walking? Do you have any skin rashes?

… Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No

¿Ha tenido artritis o reumatismo? ¿Se le hinchan y le duelen las coyunturas frecuentemente? ¿Le dan calambres fuertes en las piernas frecuentemente cuando camina? ¿A menudo le dan fuertes dolores de cabeza?

NEUROMUSCULAR/NEUROMUSCULAR Do you suffer from frequent severe headaches? Are you usually nervous? Do you often have spells of severe dizziness? Do you frequently feel faint? Have you had a loss of strength or feelings in any part of your body? Was any part of your body ever paralyzed? Did you ever have a fit or convulsion (epilepsy)? Have you ever had any broken bones? Are you constantly tired or exhausted Do you become seriously depressed? Do you feel unhappy or unwanted? Have you ever considered suicide?

… Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No

¿A menudo le dan fuertes dolores de cabeza? ¿Generalmente está Ud. nervioso? ¿Le dan vértigos frecuentemente? ¿Se siente como si se fuera a desmayar frecuentemente? ¿Ha experimentado pérdida de fuerza o de sensibilidad en alguna parte de su cuerpo? ¿Alguna vez se le ha paralizado alguna parte de su cuerpo? ¿Le ha dado algún ataque o convulsion (epilepsia)? ¿Se le ha quebrado algún hueso? ¿Se siente cansado o rendido constantemente? ¿A veces se siente profundamente deprimido? ¿Se siente infeliz y como si nadie lo quisiera? ¿Ha considerado suicidarse?

HEMATOLOGY/HEMATOLOGIA Do you bruise more easily than normal? (Estimate)

… Yes(Sí)/… No

When you cut yourself do you bleed excessively? Do you have a history of anemia (low blood count)?

… Yes(Sí)/… No … Yes(Sí)/… No

¿Le salen manchas moradas cuando se golpea más comúnmente de lo que es normal? (Calcule) ¿Sangra excesivamente cuando se corta’? ¿Ha sufrido de anemia?

ENDOCRINE/GLANDULAS ENDOCRINAS Do you have a history of having had thyroid trouble? Were you ever given thyroid tablets to take? Have you ever been told you had “gland” trouble? Do you have any lumps or bumps anywhere in your body?

… Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No

¿Ha tenido dificultad con la glándula tiroide? ¿Ha tomado pastillas para la tiroide? ¿Alguna vez le han dicho que tiene problemas glandulares? ¿Tiene usted hinchazones o chichones en alguna parte de su cuerpo? (protuberancias).

OBSTETRICS & GYNECOLOGY/OBSTETRICIA & GINECOLOGIA How old were you when you started menstruating? Are your periods usually regular? Do you have an excessive amount of bleeding with your periods? Do you frequently have pain with your periods? Have you ever had vaginal bleeding between your menstrual periods? How many children have you had? How many pregnancies have you had? Have you had a miscarriage? How many? When was your last normal period? Do you suffer from frequent vaginal discharge? Do you have vaginal buming or itching? Have you ever had a lump in your breasts? Have you ever had a bloody discharge from your nipples?

FAMILY HISTORY/Historia de Familia: Marital status/Estado civil: … Single/Soltero (a) … Married/Casado Illnesses/enfermedades Age/Edad Health/Salud Mother/Madre

_____ yrs. old … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No _____________ _____________ … Yes(Sí)/… No _____________ … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No … Yes(Sí)/… No

¿Qué edad tenía cuando comenzó la menstruación? ¿Son generalmente regulares sus períodos? ¿Sangra excesivamente durante sus períodos? ¿Frecuentemente le dan dolores con sus períodos? ¿Ha sangrado por la vagina entre sus períodos? ¿Cuántos hijos ha tenido? ¿Cuántas veces ha estado encinta? ¿Ha tenido algún aborto? Cuántos? ¿Cuando tuvo su último período regular? ¿Sufre de flujo vaginal frecuentemente? ¿Le da ardor o comezón vaginal? ¿Alguna vez ha tenido una protuberancia en los pechos? ¿Ha tenido un flujo de sangre del pezón?

… Divorced/Divorciado (a) … Widowed/Viudo (a) Age at death/Edad, si falleció

… Separated/Separado (a) Cause of death/Causa de muerte

Other Illnesses/Otras Enfermedades

Father/Padre Sisters/Hermano Brothers/Hermano Children/Hijos SOCIAL HISTORY/Historia Social Educación: Education/Educación; How many years?/ Cuánto años? _____ High School … Yes(Sí)/… No, College/Universidad ________________________________________ Masters/PHD? … Yes(Sí)/… No Special Studies?/ Estudios Especiales _____________________________________________________________________________________________________________ Psychological Treatment/Tratamiento Psicológico: … Yes(Sí)/… No Year _______ Hospitalized? … Yes(Sí)/… No Explain/ Explica: ____________________________________________Head Injuries/heridas en la cabeza_________ Habits/Habitos: Smoke cigarettes? / Fuma cigarrillos?

… Yes(Sí)/… No

How many a day? / Cuántos al dia?_________

Alcoholic beverages? / Consume bebidas alcohólicas? … Yes(Sí)/… No

To what extent? / En que cnantidad?________

Coffee Drinker? / Toma café?

How much? / Que tanto? _________________

… Yes(Sí)/… No

How many years? / Por Cuántos años? ______

Sleep: How many hours do you sleep nightly? / Cuántas horas duerme do noche? _____ Exercise: Do you have any form of regular exercise? Play sports? / Hace usted algún ejercicio regularmente? … Yes(Sí)/… No Explain: / Explique: _____________________ MILITARY HISTORY/Historia Militar Branch/Ramo_____________________ How many years?/Cuántos años____ Disabilities?/Incapacidades ______________________________________________________________________________________________________________________

LIFESTYLE CHANGES / El Cambio de la Manera de Vivir: Activities of Daily Living: Put a (C) current- in front of the activities that are difficult or painful since the accident. Put a (P) past- in front of those experienced before the injury. Escriba Ud. Una (C) entrente de las actividades que son difíciles o dolorosas desde el accidente. Escriba una (P) pasado enfrente de las que tenía Ud. antes del accidente. HOUSEWORK LOS QUEHACERES DOMÉSTCOS __Doing Laundry / Lavar la ropa __Making Beds / Hacer la cama __Vacuuming / Limpiar con aspiradora

GENERAL GENERAL __Walking / Caminar __Sitting / Sentarse __Standing / Estar de pie

PERSONAL GROOMING EL ARREGLO PERSONAL __Combing Hair / Peinarse __Shaving/Make-up / Afeitarse / Maquillaje __In/Out of Bathtub / Bañarse

__Washing Dishes / Lavar los platos __Ironing / Planchar __Carrying Groceries / Llevar comestibles __Cooking / Cocinar

__Lifting Children / Levantar a niños __Bending / Acostarse __Lying in bed/Sleeping / Doblarse / Inclinarse __Computer/Desk Work / Trabajar sentado / Computadora

__Brushing Teeth / Cepillarse los dientes __Other / Otro

__Other / Otro

__Kneeling / Arrodillarse __Sexual Intercourse / Relaciones sexuales __Sports/Exercise / Ejercicio/Deportes

__Ability to concentrate / Capacidadde concentrar __Forgetful / Olidadiza __Confuse Words / Confunde palabras

List: / ¿Cúales? ________________________

__Think Slower / Lento en pensar __Depressed / Deprimido __Personality Changes / Cambio de personalidad

YARDWORK LA JARDINERÍA __Mowing Lawn / Cortar el césped __Shoveling/Sweeping / Excaval / Barrer __Raking / Rastrillar __Gardening / Tragajar en el jardín

COGNITION PERCEPCIÓN

TRAVEL EL VIAJAR __Driving / Manejar __Riding / Viajar en carro __Getting in/out of car / Bajarse / subirse al carro

Minutes in car, truck, bus, train per day: / Minutos diario en carro, camión, autobús, tren _______________

OTHER: Please list any other difficulties you are experiencing with normal activities since this accident arose:_____________________________________________________ ____________________________________________________________________________________________________________________________________________ FOR AUTO ACCIDENTS ONLY (NOT FOR WORK INJURIES) Childhood Injuries/Falls:

Hospitalizations

Treatment

1.___________________________________________

____________________________________________

____________________________________________

2.___________________________________________

____________________________________________

____________________________________________

3.___________________________________________

____________________________________________

____________________________________________

Work Injuries: 1. Year__________ Part Injured______________ Off Work?_____ How Long?________ Disabled?__________________ Medical Treatment______________ Part Injured_______________ Case Settled? … Yes(Sí)/… No 2. Year__________ Part Injured______________ Off Work?_____ How Long?________ Disabled?__________________ Medical Treatment______________ Part Injured_______________ Case Settled? … Yes(Sí)/… No Other: _______________________________________________________________________________________________________________________________________ Car Accidents: 1. Year__________ Car Damage? … Yes(Sí)/… No Case Settled? … Yes(Sí)/… No Medical Care Given: ________________________________________________________________________________________________________Residuals? __________ 2. Year__________ Car Damage? … Yes(Sí)/… No Case Settled? … Yes(Sí)/… No Medical Care Given: ________________________________________________________________________________________________________Residuals? __________ Other: _______________________________________________________________________________________________________________________________________ Accidents or Injuries: Sports injuries, Shot, Stabbed, Stitches, Broken bones, Burns, etc. Explain:______________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________

______________________________________

(X)_____________________________________

____/____/____

PRINT PATIENT’S NAME

SIGNATURE OF PATIENT

DATE SIGNED

WORK RELATED ACCIDENT/INJURY HISTORY PERSONAL INFORMATION: Patient Name: _________________________________________________________________________________________________ Address: ____________________________________________________________ Home Phone: (____) ____-______

City: _____________________________

Today’s Date: ____/____/____

State: _____

Zip: _______________

Email: ___________________________________________________________________________________________________

Social Security #: _____/____/_____

Age:__________

Birthdate: ____/____/____

Sex: M / F

Marital Status: M S W D

Race: (optional) _________________________________________

Country of Origin: (optional) ___________________________________________________________

HISTORY OF THE INJURY Date of Injury: ____/____/____

Approximate Time: ____:____ … am/… pm

Employer’s Name: __________________________________________________________________________________________

Work Phone: (____) ____-______

Employer’s Address: __________________________________________________________________________________________________________________________ Worker’s Comp. Ins. Carrier:__________________________________________________________________________________ Adjuster: ____________________________________________________________

Phone: (____) ____-______

Claim #: ___________________________

WCAB #: _______________________

Address: ______________________________________________________________

Phone: (____) ____-______

Occupation at time of injury:__________________________________________________________________________________

# of Hours Work/Week: ___________

Attorney: ________________________

Length of employment at time of injury: _____Years _____Months

Other Part Time Job(s):______________________________________________________

Description of accident/injury: (Please give details: How it happened; how much did you lift; what hurts; etc.) ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Who did you report the injury to?________________________________________

When? ______________________________________________________________

Primary complaint at time of injury: ______________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ CURRENT COMPLAINTS - for this work injury only. Include each body area and circle 2 words that explain your pain. 1. Most Painful Area: ___________________________________________________________________________________________________________________________ Describe Pain Frequency (Check One) Describe Pain Intensity (Check One) Occasional (25%) Intermittent (50%) Frequent (75%) Constant (100%) Minimal Annoying Moderate Severe … … … … … … … … 2. Painful Area: ________________________________________________________________________________________________________________________________ Describe Pain Frequency (Check One) Describe Pain Intensity (Check One) Occasional (25%) Intermittent (50%) Frequent (75%) Constant (100%) Minimal Annoying Moderate Severe … … … … … … … … 3. Painful Area: ________________________________________________________________________________________________________________________________ Describe Pain Frequency (Check One) Describe Pain Intensity (Check One) Occasional (25%) Intermittent (50%) Frequent (75%) Constant (100%) Minimal Annoying Moderate Severe … … … … … … … … My condition is aggravated by: … Standing too long … Driving … Bowel movements … Stooping … Sitting too long … Sneezing … Pushing … Vacuuming … Lying on my back … Coughing … Pulling … Lifting over ___LBS. … Lying on my stomach … Sex … Bending … Walking long distance Other: _______________________________________________________________________________________________________________________________________ DISABILITY FROM THIS INJURY 1. Were you able to continue working at the time of injury? 2. List dates of disability for this injury: 3. Are you working now? If no, last day you worked and for whom: 4. Are you still working for the same employer? Did you quit? 5. Are you doing the same job now as when you were injured? If No, what are you doing now that is different? 6. Have you ever been disabled prior to this injury? If yes when? Ever consulted an attorney? …Y/…N

…Y/…N From: ____/____/____ to: ____/____/____ From: ____/____/____ to: ____/____/____ …Y/…N Date: ___________________________________ Employer:_______________________________ …Y/…N …Y/…N If so, when? ____/____/____ …Y/…N _________________________________________________________________________________ …Y/…N … Work related? OR … Personal Disability? From: ____/____/____ to: ____/____/____ Why? __________________________________ From: ____/____/____ to: ____/____/____ Why? __________________________________ Why? ___________________________________ Settlement? …Y/…N

Judd Chiropractic Inc. 532 Redondo Ave. Long Beach, CA 90814, Forms – Work Related Accident/Injury History.doc

(562) 439-0419, (714) 892-3131 Revised: 01/01/05

SUBSEQUENT MEDICAL TREATMENT - please list all doctors who have either examined or treated you for this injury.(in order) 1. Doctor: ____________________________________________________________________ Date: ____/____/____ Were you off work?

…Y/…N

Part treated: _________________________________________________________________________________________

Disability Given?

…Y/…N

Treatment Given: Medication, Therapy, Surgery, X-rays, Tests:_________________________________________________

Permanent Work Restrictions?

…Y/…N

Describe: ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 2. Doctor: ____________________________________________________________________

Date: ____/____/____

Were you off work?

…Y/…N

Part treated: _________________________________________________________________________________________

Disability Given?

…Y/…N

Treatment Given: Medication, Therapy, Surgery, X-rays, Tests:_________________________________________________

Permanent Work Restrictions?

…Y/…N

Describe: ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 3. Doctor: ____________________________________________________________________

Date: ____/____/____

Were you off work?

…Y/…N

Part treated: _________________________________________________________________________________________

Disability Given?

…Y/…N

Treatment Given: Medication, Therapy, Surgery, X-rays, Tests:_________________________________________________

Permanent Work Restrictions?

…Y/…N

Describe: ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Have you ever had neck or back pain or problems before this injury? …Y/…N Have you ever had a similar injury or problem like this injury? …Y/…N Have you ever had Chiropractic …Y/…N, Osteopathic …Y/…N, Orthopedic …Y/…N or Acupuncture …Y/…N care before? Have you had any special tests for this injury? (check box) … MRI scan … CAT scan … EMG/Nerve conduction … Bone scan … Lab … ECG … Xrays Other: _______________________________________________________________________________________________________________________________________ JOB DESCRIPTION AT TIME OF INJURY: Job Title _______________________________________________________________________________________________________________ Years at this job? _____ 1. In a typical 8-hour workday, I: (Check # of hours for each activity) 1 2 3 4 5 6 7 8 Hours … … … … … … … … Sit: … … … … … … … … Stand: … … … … … … … … Walk: 2. On the job, I perform the following activities: Not at all Occasionally (0% to 33% of day) Frequently (34% to 66% of day) Continuously (67% to 100% of day) … … … … Bend/Stoop: … … … … Squat: … … … … Crawl: … … … … Climb: … … … … Reach above shoulder level: … … … … Crouch: … … … … Kneel: … … … … Balancing: … … … … Pushing/Pulling: 3. On the job, I lift: Not at all Occasionally (0% to 33% of day) Frequently (34% to 66% of day) Continuously (67% to 100% of day) … … … … Up to 10 pounds: … … … … 11 to 24 pounds: … … … … 25 to 34 pounds: … … … … 35 to 50 pounds: … … … … 51 to 74 pounds: … … … … 75 to 100 pounds: 4. Do you have to bend over while doing any lifting? …Y/…N 5. Are your feet used for repetitive movements, such as in operating foot controls? …Y/…N 6. Do you use your hands for repetitive actions, such as: SIMPLE GRASPING FIRM GRASPING FINE MANIPULATING Right Hand: …Y/…N …Y/…N …Y/…N Left Hand: …Y/…N …Y/…N …Y/…N 7. Are you required to work on unprotected height? …Y/…N 9. Are you required to be around moving machinery? …Y/…N Describe: ____________________________________________________________________________________________________________________________________ 10. Are you exposed to marked changes in temperature and humidity? …Y/…N 11. Are you required to drive automotive equipment while working? …Y/…N 12. Are you exposed to dust, fumes, and /or gasses? …Y/…N 13. Please list any additional comments: ____________________________________________________________________________________________________________

14. Lift over the waist, shoulder, or head?

…Y/…N

PRIOR WORK HISTORY – from your most recent job backwards Employer: ____________________________________ Job: ________________________________________________

From: ____/____/____ to: ____/____/____

Employer: ____________________________________

Job: ________________________________________________

From: ____/____/____ to: ____/____/____

Employer: ____________________________________

Job: ________________________________________________

From: ____/____/____ to: ____/____/____

Employer: ____________________________________

Job: ________________________________________________

From: ____/____/____ to: ____/____/____

PRIOR WORK INJURIES AND DISABILITIES 1. Employer: __________________________________________________________________

Date: ____/____/____

Were you off work?

…Y/…N

Part Injured: _________________________________________________________________________________________

Disability Given?

…Y/…N

Treatment Given: Medication, Therapy, Surgery, X-rays, Tests:_________________________________________________

Permanent Work Restrictions?

…Y/…N

Describe: ___________________________________________________________________________________________

Did you get a Settlement?

…Y/…N

____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 2. Employer: __________________________________________________________________

Date: ____/____/____

Were you off work?

…Y/…N

Part Injured: _________________________________________________________________________________________

Disability Given?

…Y/…N

Treatment Given: Medication, Therapy, Surgery, X-rays, Tests:_________________________________________________

Permanent Work Restrictions?

…Y/…N

Describe: ___________________________________________________________________________________________

Did you get a Settlement?

…Y/…N

____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ PAST RELEVANT MEDICAL HISTORY: INJURIES AND ACCIDENTS OF A NON WORK RELATED NATURE - please list all of them (Auto accidents; Falls; Sports injuries; Shot; Stabbed; Beaten up; Stitches; Broken bones; Burns; Etc.) 1. ______________________________________________________________________________ Date: ____/____/____ Residual/Still Have Pain?

…Y/…N

Part Injured: __________________________________________________________________________________________________________________________________ Treatment Given: Medication, Therapy, Surgery, X-rays, Tests:__________________________________________________________________________________________ Describe: ____________________________________________________________________________________________________________________________________ 2. ______________________________________________________________________________

Date: ____/____/____

Residual/Still Have Pain?

…Y/…N

Part Injured: __________________________________________________________________________________________________________________________________ Treatment Given: Medication, Therapy, Surgery, X-rays, Tests:__________________________________________________________________________________________ Describe: ____________________________________________________________________________________________________________________________________ 3. ______________________________________________________________________________

Date: ____/____/____

Residual/Still Have Pain?

…Y/…N

Part Injured: __________________________________________________________________________________________________________________________________ Treatment Given: Medication, Therapy, Surgery, X-rays, Tests:__________________________________________________________________________________________ Describe: ____________________________________________________________________________________________________________________________________ 4. ______________________________________________________________________________

Date: ____/____/____

Residual/Still Have Pain?

…Y/…N

Part Injured: __________________________________________________________________________________________________________________________________ Treatment Given: Medication, Therapy, Surgery, X-rays, Tests:__________________________________________________________________________________________ Describe: ____________________________________________________________________________________________________________________________________ 5. Other: _____________________________________________________________________________________________________________________________________ Surgeries, Allergies, Medications, Illnesses on Medical Health Questionnaire (office use only) ______________________________________ PRINT PATIENT’S NAME

(X)_____________________________________ SIGNATURE OF PATIENT

____/____/____ DATE SIGNED