Accidents Happen, We Happen To Heal Them
First Name*
Last Name*
Date of Birth*
Address*
Phone Number*
Email*
Gender*
MaleFemale
Marital Status*
SingleMarriedWidowedDivorced
Attorney Name/Group
Police Report Filed?*
YesNo
Third Party Insurance Info
Emergency Contact Info*
Dominant Hand
Right-handedLeft-handed
Medical History (Select all that apply)
AsthmaCOPDHypertensionArrhythmiaDiabetesThyroid problemsKidney problemsDialysisBladder problemsEpilepsy/SeizuresAnxietyDepressionPTSDInsomniaADD/ADHDOther
If Other, please specify:
Medications and Doses
Pharmacy Name
Pharmacy Phone Number
Pharmacy Address
Prior Head Injuries?
Medication Allergies (to medications only)?
If yes, please specify medication and reaction
Previous Surgeries (include approximate year)
Social & Family History
Social History (Select all that apply)
AlcoholTobaccoIllicit DrugsNone
Social History Details (if applicable, please specify frequency and type)
Family Medical History
Date of Accident*
Role in the Accident
DriverPassenger (front)Passenger (behind driver)Passenger (back middle)Passenger (behind front passenger)
Type and Size of Vehicle
City where Accident Occurred
Where was the vehicle contacted?
Front endRear endDriver's sidePassenger's side
Head Position at Impact
Facing forwardTurned to the leftTurned to the rightOther
Did you experience whiplash?
YesNoUnsure
If yes, how?
Did you hit your head on anything?
If yes, please specify (e.g., headrest, window, pillar):
Did you lose consciousness?
If yes, for how long?
Symptoms Immediately After the Accident (Select all that apply)
HeadacheNeck painDizzinessRinging in the earsFeeling disorientedFeeling like you were in a state of shock
Memory Recall Issues
Difficulty recalling events BEFORE the accidentDifficulty recalling events AFTER the accidentNo difficulty
Hospital Visit
Yes, I went immediatelyNo, I did notOther
If hospital visit, list tests done:
Medications Prescribed at Hospital
Diagnoses Received
ConcussionWhiplash injuryNone
If no immediate hospital visit, when and where did you receive care?
Other Doctors Seen for This Injury (e.g., Chiropractor, Physical Therapist, Primary Doctor, Neurologist, Psychiatrist, Orthopedic Surgeon, Other)
Diagnostic Tests Performed
Current Headache Status
Duration of Headaches
Headache Evolution since the accident
Never had headaches after accidentHad headaches after accident but they stoppedStill have headaches but not as bad as immediately after accidentStill have significant headaches
If headaches stopped, when did they stop?
How often do you get headaches now?
Current Headache Severity
Please rate your headache severity on a scale from 1 to 10, where 1 = minimal or no pain, 5 = moderate pain, and 10 = extreme, incapacitating pain.
Headache Character
Throbbing/PulsingPressing/SqueezingStabbingSharpDull/NaggingAchy
Headache Location
R-SideL-SideEither SideBackTopTemplesForeheadFaceNeckBoth SidesBehind/Around EyesOther
If other, please specify headache location
Light Sensitivity associated with your headaches
Noise Sensitivity associated with your headaches
Nausea or Vomiting associated with your headaches
Select oneYes, nauseaYes, vomitingYes, nausea and vomitingNo
If applicable, specify frequency of these sensitivities
Vision Changes associated with your headache
If yes, please describe vision changes
Noise Sensitivity (Not Associated with Headache)
Light Sensitivity (Not Associated with Headache)
TINNITUS (Ringing in the Ears)
Yes, more in the left earYes, more in the right earYes, only in the left earYes, only in the right earYes, equal in both earsNo
If tinnitus, frequency (per day/week/month)
If tinnitus, duration (seconds/minutes/hours/days)
How often is the tinnitus associated with your headaches?
AlwaysUsuallySometimesRarelyNever
Dizziness Symptoms (Select all that apply)
Room is spinningFeeling wobblySwaying left or rightWorsens when I move quicklyFeeling lightheadedNone
Dizziness Frequency (per day/week/month)
Dizziness Duration (seconds/minutes/hours/days)
Dizziness Severity
Please rate your dizziness severity on a scale from 1 to 10, where 1 indicates minimal dizziness and 10 indicates severe, incapacitating dizziness.
Daytime Tiredness/Lethargy
Please rate your level of daytime tiredness on a scale from 1 to 10, where 1 indicates minimal or no fatigue and 10 indicates severe, debilitating fatigue.
Have you experienced a stronger sense of urgency when needing to pee after the accident?
Vision Changes after the Accident (not related to headaches)?
If Yes, describe Vision Changes
Current Sleep Problems
Time to Fall Asleep BEFORE the Accident
Time to Fall Asleep CURRENTLY
Times Waking Up at Night BEFORE the Accident
Times Waking Up at Night CURRENTLY
Frequency of Naps during the Day BEFORE the Accident
Frequency of Naps during the Day CURRENTLY
Current Mood Problems
Have you experienced Irritability?
If Yes, rate your irritability (Scale 1-10)
Who has mentioned your irritability? (Select all that apply)
PartnerKidsFriendsCoworkers
Have you been Crying more often?
Frequency of Crying BEFORE the Accident
Frequency of Crying AFTER the Accident
Feeling like you want to Cry more often?
Frequency of Feeling like Crying BEFORE the Accident
Frequency of Feeling like Crying NOW
Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things?
Select oneNot at allSeveral daysMore than half the daysNearly everyday
Feeling down, depressed, or hopeless?
Trouble falling or staying asleep, or sleeping too much?
Feeling tired or having little energy?
Poor appetite or overeating?
Feeling bad about yourself?
Trouble concentrating?
Psychomotor changes (moving/speaking slowly or being restless)?
Suicidal ideation (thoughts that you would be better off dead or of hurting yourself)?
Over the last two weeks, how often have you been bothered by feeling nervous, anxious, or on edge?
Not being able to stop or control worrying?
Worrying too much about different things?
Trouble relaxing?
Being so restless that it is hard to sit still?
Becoming easily annoyed or irritated?
Pseudobulbar Affect
Select oneApplies neverApplies rarelyApplies occasionallyApplies frequentlyApplies most of the time
I find myself becoming amused very easily
I find myself crying very easily
I find that even when I try to control my laughter, I am often unable to do so
There are times when I suddenly become overcome by happy thoughts
I find that even when I try to control my crying, I am often unable to do so
I find that I am easily overcome by laughter
Sensation of Mind Fogginess?
Takes more time and energy to think and process information?
Difficulty concentrating?
Feel overwhelmed easily in crowded rooms?
More forgetful?
List any symptoms that concern you regarding memory or thinking problems
Insurance Payment/Financial Responsibility Release
I request that payment insurance benefits be made to either me or on my behalf to Sol Medical for any services furnished to me by the Physician/Provider. I authorize any holder of my medical information concerning me to be released to my insurance carrier or Health Care Financing, its agents; any information needed to determine these benefits or the benefits payable for related services. A photocopy of this authorization shall be considered effective and valid as the original. I understand that I am financially responsible for all charges not covered by my insurance company.
Notice of Privacy
To Our Patients: This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Our practice is committed to protecting your privacy. Please review our full Notice of Privacy Practices for further details.
Assignment, Lien, Authorization of Insurance Benefits and Power of Attorney
I hereby authorize and direct any insurance company and/or my attorney to pay directly Sol Medical sums as may be due and owing the office for services rendered to me, both by reason of accident or illness, and by reason of any other bills that are due this office, and to withhold such sums from any disability benefits or any other insurance benefits obligated to reimburse me or from any settlement, judgment or verdict on my behalf as may be necessary to adequately protect said Office. I hereby further give a lien to said Office against any and all insurance benefits that I may be entitled to and any and all proceeds for any settlement, judgment or verdict which may be paid to me as a result of the injuries or illness for which I have been treated by said Office. This is to act as an assignment of my rights and benefits to the extent of the Office’s services provided.
I hereby assign all of my interest and rights to PIP benefits, which shall include, but not be limited to, the right to file a PIP suit or seek arbitration for PIP benefits relative to treatment by said Office. I hereby assign and transfer to this Office any and all causes of action that I might have or that might exist in my favor against any insurance carrier that may be liable for payment of PIP benefits, and authorize this Office to prosecute said cause of action either in my name or in the Office’s name. Furthermore, I authorize this Office to compromise, settle, or otherwise resolve said claim or cause of action as they see fit. In the event that the within assignment is not consented to by an insurer or in any other manner is held invalid by any party, arbitrator, or any other person, I hereby give this Office the power of attorney to bring any arbitration proceeding or suit in my name on my behalf as if I had filed such action myself. I further agree to fully cooperate with regard to prosecuting such action or proceeding.
I understand that I remain personally responsible for the total amounts due the Office for services rendered, subject to Arizona/California law. I further understand and agree that this Assignment, Lien, and Authorization does not constitute any consideration for the Office to await payments and that they may demand payments from me immediately upon rendering services at their option. I further understand and agree that should I receive any payments made on my behalf from any insurance company, I will endorse the check over to Sol Medical within 30 days of receipt, and I fully understand that failure to do so may result in collections procedures against me.
I authorize this Office to release any information pertinent to my case to any insurance company, adjuster, or attorney to facilitate collection under this Assignment, Lien, and Authorization, provided that the request is submitted in writing. I agree that the above-mentioned Office is hereby granted Power of Attorney to endorse/sign my name on any and all checks for payment of my doctor’s bill. I further authorize any insurance company and any other physicians who have treated me for this accident to provide this Office with any documentation needed regarding the payment of my bills.
I acknowledge and agree to the Insurance Payment/Financial Responsibility Release, the Notice of Privacy, and the Assignment, Lien, Authorization of Insurance Benefits and Power of Attorney.*
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