1809 Springdale St, Suite 102
Mt. Horeb, WI 53572
608-437-2222
www.vikesteinichchiro.com

NEW PATIENT INTAKE FORM -- Personal Injury	Today’s Date 	/ 	/ 	

PATIENT INFORMATION	CONFIDENTIAL
Thank you for the opportunity to serve you. If you have any questions, do not hesitate to ask. We will be happy to  help.

Name				 First	MI	Last

DOB 	/ 	/ 	

S/S 	- 	- 	

Address 	City 	State 	Zip 	
Please check your preferred method of contact

❐Home Phone:  	
❐Cell Phone:  	

❐Work Phone:  	
❐e-mail address*: 	

* Your e-mail will not be shared with any 3rd parties and is used for occasional office announcements and promotions.
Height 	Weight 		Last known Blood Pressure: 		(Unsure? We can take a reading today) Do you smoke: ❐ No❐ Yes (If yes how often 	) If you quit: Start date: 	End Date:  	  Sex:        ❐ Female	❐ Male		Status:  ❐ Minor		❐Married		❐Single		❐ Other: 	
Ethnicity/Race: 	Employed: ❐Full-Time ❐Part-Time	❐Student
Your Employer 	Occupation 	
Business Address 	City 	State 	Zip 	
Who may we thank for referring you to us? 	
Person to contact in case of an emergency 	Phone 	
INSURANCE CO. 	Policy #  	  Name on Policy (if not self)  		  Responsible Party’s Name 	Agent’s name  	  Address		 ATTORNEY 	Phone	 Address  		 

HEALTH HISTORY
Please check the following symptoms you have noticed SINCE THE ACCIDENT (❍) or BEFORE THE ACCIDENT (❐):
❍ ❐	Headaches	❍ ❐	Cold Feet	❍ ❐	Fainting	
❍ ❐	Neck Pain	❍ ❐	Nervousness	❍ ❐	Dizziness	
❍ ❐	Neck Stiffness	❍ ❐	Tension	❍ ❐	Loss of Balance	
❍ ❐	Mid Back Pain	❍ ❐	Irritability	❍ ❐	Light Sensitivity with Eyes	
❍ ❐	Low Back Pain	❍ ❐	Mood Swings	❍ ❐	Ringing/ Buzzing in Ears	
❍ ❐	Arm Pain	❍ ❐	Sleeping Problems	❍ ❐	Loss of Memory	
❍ ❐	Leg Pain	❍ ❐	Fatigue	❍ ❐	Loss of Smell	
❍ ❐	Pins and Needles in Arms	❍ ❐	Depression	❍ ❐	Loss of Taste	
❍ ❐	Pins and Needles in Legs	❍ ❐	Chest Pain	❍ ❐	Upset Stomach	
❍ ❐	Numbness in Fingers	❍ ❐	Shortness of Breath	❍ ❐	Constipation	
❍ ❐	Numbness in Toes	❍ ❐	Cold Sweats	❍ ❐	Diarrhea	
❍ ❐	Cold Hands	❍ ❐	Fever	❍ ❐	Urinary Problems	

❍	❐ Heartburn
❍	❐ Ulcers
❍	❐ Allergies
❍	
❐ Menstrual Pain
❍	❐ Menstrual Irregularity
❍	❐ Hot flashes
❍	
❐ Other  	
❍	❐ Other  	
❍	

Have YOU  (❍) or A FAMILY MEMBER  (❐) ever been diagnosed with any of the following conditions:
❍ ❐	AIDS/HIV	❍ ❐	Heart Disease	❍ ❐	None	
❍ ❐	Cancer	❍ ❐	Diabetes	❍ ❐	Unknown	
❍ ❐	High Blood Pressure	❍ ❐	Stroke	❍ ❐	Other  		

NATURE OF ACCIDENT
Date of accident 	/ 	/ 	

Time of Day 	Location of accident  	

Relative speed of you car 	(mph)	Relative speed of the other car 	(mph) What was the site of impact on your car?		Where were you sitting at the time of impact?
❒	Behind	❐ Front	❐ Driver
❒	Driver’s Side	❐ Passenger’s Side		❐ Passenger …. ❐ Front ❐ Back Were you wearing your seat belt?... ❐ No  ❐ Yes	Did your airbags deploy?   ❐ No  ❐ Yes Were your brakes applied?……..… ❐ No  ❐ Yes	Did your seat back break? ❐ No   ❐ Yes
At time of accident were you looking:      ❐Straight ahead     ❐Up    ❐Down    ❐Right    ❐Left  
PLEASE DESCRIBE THE ACCIDENT in your own words, in detail:  	

List any parts of your body that struck the following vehicle parts during the accident:
Dashboard: 	Door:			 Windshield: 	Door Window:  		 Steering Wheel: 	Other:			 Your Vehicle Type 	Other Vehicle Type  		 Did you lose consciousness?   ❐ No   ❐ Yes, for how long?  	      	
ADDITIONAL INFORMATION:
What was your mental and emotional state immediately following the accident?  		  Were the police notified?   ❐ No   ❐ Yes  Did you receive medical attention at the scene of the accident?   ❐ No  ❐ Yes Where did you go immediately following the accident?  	 Have you been treated by another doctor since the accident?   ❐ No   ❐ Yes , If yes…
Please list the name of the doctor and address:  	 Please explain what type of treatment you received:  	  What type of X-rays were taken if any?  	 
Do you have any congenital (from birth) factors that may relate to this problem?   ❐ No   ❐ Yes,  	
Do you have any previous illnesses which relate to this case ❐ No ❐ Yes,  		  Have you ever been involved in an accident before?   ❐ No  ❐ Yes,  	  Have you lost time from work as a result of this accident?   ❐ No    ❐ Yes, If yes…

Last day worked: 	/ 	/ 	
PLEASE DESCRIBE HOW YOU FELT:

Type of employment:  	

DURING the accident:  	  IMMEDIATELY AFTER the accident:  	  LATER THAT DAY:  	  THE NEXT DAY:  	

Please add any other information that you feel is pertinent: _ 	

PLEASE LIST YOUR CURRENT AREAS OF COMPLAINT:
(chief complaint)
1) 	2) 	3) 	4)  	
0  1  2  3  4  5  6  7  8 9 10	0  1  2  3  4  5  6  7  8 9 10	0  1  2  3  4  5  6  7  8 9 10	0  1  2  3  4  5  6  7  8  9 10

.CIRCLE THE NUMBER THAT BEST DESCRIBES THE INTENSITY OF YOUR PAIN: 1 = Mild, 10 = Severe

PLEASE MARK YOUR AREAS OF COMPLAINT ON THE BODY DIAGRAM USING THE FOLLOWING KEY:
Dull	= D
Aching	= A
Stiffness	= S
Burning	= B
Tingling	= T
Numbness	= N
Sharp	= !!!
Shooting	= XXX

  
  How often do you notice your symptoms?	❐ Constantly	❐ Frequently	❐ Occasionally
Does anything relieve your pain? 						  What activities are difficult to perform?	❐Sitting	❐Standing	❐Walking	❐Bending	❐Lying Down
Please describe any other activities that are restricted due to this injury? 	

Is the condition getting worse? ❐ No    ❐ Yes   ❐ Same    ❐Other________________________________________________
Have you had this problem before? ❐ No ❐ Yes, When? 		  Have you ever been diagnosed with a Subluxation?  ❐ No    ❐ Yes,      When?  	 Have you had x-rays before? ❐ No    ❐ Yes,  When? 	What areas?  	  I am currently taking the following medications for the following reasons:   ❐ None

List Allergies: Surgical History:
For Women Only: Is there a possibility that you may be pregnant?	❐ No    ❐ Yes

Which best describes your health goals:   ❐pain relief only	❐correct entire problem	❐ wellness/ preventative care

I certify that the above information is true and accurate to the best of my knowledge

DATE: 	/ 	/ 		SIGNATURE:  	

PARENT/GUARDIAN: