ACCIDENT/INJURY Q - Chiropractor Peoria IL

Patient No: ___________ © Pinnacle Management Group, Inc. 2013

of 1

ACCIDENT/INJURY QUESTIONNAIRE

Name: (Last, First MI)____________________________________ Today’s Date: ___________

AUTOMOBILE ACCIDENT – ADDITIONAL INFORMATION

• Was anyone else in the vehicle with you? No Yes - (Number of people) ______

• You were? Front seat – Driver / Passenger Rear Seat– Behind Driver / Middle / Behind Passenger / 2nd Row / 3rd Row

• Name of Driver, if not self: ____________________ Name of Driver of other vehicle: ________________________________

• Did airbags deploy? No Yes Did Police arrive? No Yes Using Seatbelt? No Yes

• Did you strike the windshield or object in car? No Yes - (Describe) ____________________________________________

• Were you knocked unconscious? No Yes (How long?) _________

• Where was your vehicle impacted? Front / Rear / Passenger Side / Driver’s Side / Other: ________________________________

• Where was the other vehicle impacted? Front / Rear / Passenger Side / Driver’s Side / Other: ____________________________

• Your Auto Ins: _________________ Policy #: _______________ Claim #: _____________________ Phone #:______________

o Address: _______________________________________ City: _____________________ State: _______ Zip: ___________

• Other’s Auto Ins: _________________ Policy #: _______________ Claim #: _____________________ Phone #:____________

o Address: _______________________________________ City: _____________________ State: _______ Zip: ___________

WORKER’S COMPENSATION INJURY – ADDITIONAL INFORMATION

Employer: __________________________________ Occupation: _________________ Claim #: ___________________________

Address: ___________________________________ City: ________________________ State: ________ Zip: ________________

Contact Person: _____________________________ Phone: ______________________ Email: ____________________________

GENERAL ACCIDENT/INJURY INFORMATION – (PLEASE USE THE REVERSE SIDE OF THIS PAGE IF ADDITIONAL SPACE IS NEEDED)

Date of Accident: ____/____/______ Time: ___:_____ AM / PM

Please describe the accident in as much detail as possible? __________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Before the accident/injury: • Have you ever had any complaints in the involved area before? No Yes

o If yes - Were they present at the time of the accident/injury? No Yes

If yes - Summarize these complaints prior to the accident: _______________________________________ • Were you capable of performing all of your work activities without restriction? No Yes

At the time of the accident/injury: • Did you feel pain immediately after the accident? No Yes Later that day Next day When? ______________

• Were you taken anywhere after the accident? No Yes Later that day Next day When? _________________

o If yes, How?___________________________ Where?_________________________

o If yes, Did you receive treatment? No Yes - (Describe) __________________________________________________

Since the accident/injury: • Are your symptoms: Improving? Getting Worse? The Same?

• Are your work activities restricted as a result of this accident/injury? No Yes - ( How?) _________________________________

• Have you missed any work since this accident? No Yes - (Dates?) ___________________________________________

• Have you retained an Attorney? No Yes - Name:_______________________________ Phone: __________________

o Address: __________________________________ City: _____________________ State: _______ Zip: _____________

AUTOMOBILE ACCIDENT QUESTIONNAIRE Patient's Name:_____________________________ Today's Date:__________ Date of Accident:____________________________ THE FOLLOWING QUESTIONS PERTAIN TO YOU AND THE VEHICLE YOU WERE IN: Vehicle type: Vehicle size:

Car Pickup Subcompact Full-size Van Truck Compact Mini Station Wagon Bus Mid-size Light Other________________ Heavy Other_________________

Your position in the vehicle:

Driver Passenger -------- Location-------- Left Middle Right Other _________________ Front Passenger Rear Passenger Third Seat (rear)

Speed of your vehicle: Why Vehicle was slowed or stopped:

Stopped Moving Moderately Traffic Signal Parking Parked Moving Fast Pedestrian Traffic Slowing Moving at apprx ____MPH Stop Sign Busy Intersection Moving Slowly

Collision Type:

Driver Side Impact Head On Collision Passenger Side Impact Rear Impact Front Impact Pedestrian Incident

THE FOLLOWING QUESTIONS CONCERN THE OTHER VEHICLE INVOLVED IN THE ACCIDENT: Vehicle type: Vehicle size:

Car Pickup Subcompact Full-size Van Truck Compact Mini Station Wagon Bus Mid-size Light Other________________ Heavy Other_________________

CONDITIONS AT THE TIME OF THE ACCIDENT: Time of day: Road Conditions: Visibility: Visibility compromised by:

Full daylight Dry Excellent Brightness Damp Good Darkness

Dusk Wet Fair Rain Night Snow covered Poor Snow

Ice covered Fog Patchy Ice/Snow Traffic THE FOLLOWING QUESTIONS CONCERN THE MOMENT OF IMPACT OF THE ACCIDENT: Were you... Restraints: (check all that apply)

Totally unaware that the accident was impending Seat belt Aware that the accident was impending Shoulder harness Aware that the accident was impending and braced for it No restraints

If you were the driver of the vehicle, was your foot on the brake pedal? Yes No Knocked off by impact Was the air bag deployed? What position was YOUR headrest in?

Car not equipped with air bag High position Air bag deployed Middle position Air bag not deployed Low position

Position of YOUR head at time of impact? Was your head thrown...? Facing straight ahead Backward and then forward Tilted forward Forward then backward Rotated to the left To the left To the left then the right Rotated to the right To the right To the right, then the left

Position of Your body at time of impact? Was your body thrown...?

Straight Backward and then forward Tilted forward Forward then backward Rotated to the left To the left To the left then the right Rotated to the right To the right To the right, then the left Across the vehicle Outside the vehicle Under the vehicle Damage to vehicle YOU were in: Citations:

Incurred minimal damage None issued Incurred moderate damage Yourself Incurred severe damage Driver of vehicle patient was a passenger of Was totaled Driver of other vehicle Not known Not sure

AS A RESULT OF THE FORCE OF THE COLLISION, WHICH OBJECTS IN THE VEHICLE DID YOUR BODY STRIKE? Head Left Arm

Steering wheel Right door Steering wheel Right door Dashboard Left window Dashboard Left window Windshield Right window Windshield Right window Armrest Console Armrest Console Headrest Gear shift Headrest Gear shift Rear view mirror Front seat Rear view mirror Front seat Left door Backseat Left door Backseat

Right Arm Torso


Left Leg Right Leg


THE FOLLOWING QUESTIONS CONCERN THE TIME PERIOD IMMEDIATELY FOLLOWING THE ACCIDENT: Did you lose consciousness? Immediately following the accident, did you feel...?

Yes Dizzy Weak No Dazed Nervous

Disoriented Nauseated

Were you able to walk unaided? Where did you go...? Yes Drove home Drove to work No Was driven home Was driven to work

Drove to hospital Drove to school Was driven to hospital Was driven to school Taken to hospital via ambulance Next day discomfort...? Did your major complaints exist before the accident?

increased decreased same Yes No In what areas did you IMMEDIATELY feel pain?

Head Shoulder Left Right Hip Left Right Neck Arm Left Right Thigh Left Right Upper back Elbow Left Right Knee Left Right Mid back Wrist Left Right Calf Left Right Ribs Hand Left Right Ankle Left Right Chest Fingers Left Right Foot Left Right Abdomen Buttock Left Right Toes Left Right Low Back Pelvis

In what areas did you experience lacerations (cuts)? Head Shoulder Left Right Hip Left Right Neck Arm Left Right Thigh Left Right Upper back Elbow Left Right Knee Left Right Mid back Wrist Left Right Calf Left Right Ribs Hand Left Right Ankle Left Right Chest Fingers Left Right Foot Left Right Abdomen Buttock Left Right Toes Left Right Low Back Pelvis

At the hospital, what areas were x-rayed? Head Shoulder Left Right Hip Left Right Neck Arm Left Right Thigh Left Right Upper back Elbow Left Right Knee Left Right Mid back Wrist Left Right Calf Left Right Ribs Hand Left Right Ankle Left Right Chest Fingers Left Right Foot Left Right Abdomen Buttock Left Right Toes Left Right Low Back Pelvis

Where did you experience pain on the day FOLLOWING the accident? Head Shoulder Left Right Hip Left Right Neck Arm Left Right Thigh Left Right Upper back Elbow Left Right Knee Left Right Mid back Wrist Left Right Calf Left Right Ribs Hand Left Right Ankle Left Right Chest Fingers Left Right Foot Left Right Abdomen Buttock Left Right Toes Left Right Low Back Pelvis

Tuttle Chiropractic

6808 N Knoxville Ave Ste B

Peoria IL 61614

Patient Name:__________________________D.O.B.:________________Date:___________________

Consent for Chiropractic Services

By reading below I have been made aware:

1. The process of delivering a “Chiropractic Adjustment (manipulation)” may be

performed manually, with a table mechanism, or with an instrument to the vertebra(e) of the

spine and/or associated structures (legs, arms etc.), often resulting in an audible pop or click

sound;

2. As an addition to the Chiropractic Adjustment “Supportive Therapies and/or

Procedures” may be applied by the chiropractor or by staff under the chiropractor’s direction or

supervision incorporating the use of light, sound, vibration, electricity, traction, motion, bracing,

nutritional advice, heat, or cold;

3. That on occasion some temporary soreness and/or stiffness may occur; less

frequently aggravation of presenting symptoms or initiation of new symptoms; rarely bruising,

swelling, even more rare separation/fracture; and extremely rare, nerve or vascular injury may

occur in conjunction with the process of a Chiropractic Adjustment;

4. That the chiropractor has made no guarantee of a positive outcome from

treatment.

Additionally:

1. I have been afforded ample opportunity for questions and answers.

Therefore by signing below:

I consent to the performance of the diagnostic and therapeutic procedures performed by

the doctor and or staff under the direction and supervision of the office chiropractor(s)

involved in my case;

I consent to the performance of other diagnostic and therapeutic procedures in the future

that may be deemed reasonable and necessary by the doctor and or staff under the

direction and supervision of the office chiropractor(s) involved in my case;

Patient Signature: ________________________________________

Witness Signature: ________________________________________

www.chiroevidence.com

Health and Medical Information Release

I, _________________________________, give permission to Dr. Justin Tuttle and Staff

at Tuttle Chiropractic to share medical information with my medical doctor,

_________________________________, as well as his/her staff. Also, my medical

doctor and staff have permission to share medical information with Dr. Tuttle and his

Staff.

Signature: _________________________________ Date: ____________________

Patient Information

Name: __________________________________________________________________

Address: ________________________________________________________________

City, State, Zip: __________________________________________________________

Phone: ___________________________________ Date of Birth: __________________

Medical Doctor Information

Name of Doctor: _________________________________________________________

Address: ________________________________________________________________

City, State, Zip: __________________________________________________________

Phone: _________________________________________________________________

HIPAA Notice of Privacy Practices

TUTTLE CHIROPRACTIC THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND

HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operation (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Uses and disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Healthcare Operation: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food Drug Administration requirements: Legal proceedings: Law Enforcement: Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to your and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization or Opportunity to Object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of , or use in a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to restriction that you may request. If physician believes it is in your best interest to permit use a disclosures of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filling a complaint. This notice was published and becomes effective on/or before April14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number. Signature below is only acknowledgement that you have received this Notice of our Privacy Practices: Print Name: _____________________________ Signature ________________________ Date _________________

HISTORY OF PRESENT ILLNESS

Account No: ______ © Seamless, LLC Page 1 of 1

Revision Date 03/01/2017

HISTORY OF PRESENT ILLNESS (Please describe)

Major Complaint: ____________________________________ ____________________________________________

____________________________________________

Secondary Complaints: ________________________________ ____________________________________________

____________________________________________

When did it start? ____/____/_____ What happened? ______________________________________________________________

___________________________________________________________________________________________

Which daily activities are being affected by this condition? ____________________________________________________________

___________________________________________________________________________________________

MAJOR COMPLAINT

Location of Symptoms and Radiation

P __ Pain T__ Tender

N __ Numb H__ Hypoesthesia

S __ Spasm

Grade Intensity/Severity:

None (0/10)

Mild (1-2/10)

Mild-Moderate (2-4/10)

Moderate (4-6/10)

Moderate-Severe (6-8/10)

Severe (8-10/10)

Frequency:

Off & On

Constant

Quality:

Sharp

Stabbing

Burning

Achy

Dull

Stiff & Sore

Other: __________________

Does it radiate?

No Yes (Please indicate on drawing)

Improves with:

Ice

Heat

Movement

Stretching

OTC Medications: ______________

Other: _______________________

Worsens with:

Sitting

Standing/Walking

Lying Down/Sleeping

Overuse/Lifting

Other: __________________________

Previous Treatment:

None

Chiropractor _____________________

Medical Doctor ___________________

Physical Therapy _________________

ER/Urgent Care __________________

Orthopedic ______________________

Other: __________________________

Previous Diagnostic Testing:

None

X-rays __________________________

MRI ___________________________

CT _____________________________

Other: __________________________

*Women: Are you pregnant?

No Last Menstrual Period: ___/___/____

Yes Due date: ___/___/____

Present Illness Comments:

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

Prescription Medications & Supplements: None

Yes (List – Name, dosage, frequency) ________________________

___________________________________________

___________________________________________

___________________________________________

Allergies to Medications: No known drug allergies

Yes (List - Name and reaction)_____________________________

___________________________________________

___________________________________________

___________________________________________

I have answered these questions to the best of my knowledge and certify them to be true and correct.

Patient or Guardian Signature ________________________________________________________ Date______________________

Print Name: (First MI Last) ____________________________________________________________

R R L L

R

L

INTRODUCTION PATIENT CASE HISTORY

Account No: ___________ © Seamless, LLC

Page 1 of 1 Revision Date 03/14/2017

Today’s Date: ____/____/_____

PATIENT INFORMATION

Name: (First MI Last) ________________________________________________________ Preferred Name: __________________

Address: _________________________________________ City: __________________ State: _______ Zip: ________________

Date of Birth: ___________ Gender: Male Female Social Security #:_________________

Home: _________________ Mobile: _________________ Work: _________________

Email: ____________________________________________

Preferred Method of Contact: Text Email Phone - Home, Mobile, or Work Other: ___________

*Referred By: (Name) _____________________________

Family Friend Co-Worker Doctor Other: ___________

Race & Ethnicity: (Choose up to 2) Preferred Language:

African American or Black English

American Indian or Alaskan Native Spanish

Asian Other: _______________

Hispanic or Latino Decline

Native Hawaiian or Other Pacific Islander

White

Decline

EMERGENCY CONTACT INFORMATION

Name: (First MI Last) ____________________________________

Home: ___________________ Mobile: ___________________

Relationship:

Primary Care Physician: ______________________________

Doctor’s Phone: _____________________________________

Child Parent Spouse Other: ______________

FINANCIAL INFORMATION

Is today’s visit the result of an accident?

No Auto Work Other: __________

Will we be working with insurance? No Yes (Details)

Primary: _______________________ ID#: _______________

Secondary: _______________________ ID#: _______________

Where would you like statements sent?

Self Other (Details below)

Name: _______________________________________________

Address: _____________________________________________

Phone: ________________ Email: _________________________



It is Usual and Customary to Pay for Services as Rendered Unless Otherwise Arranged

PAST, FAMILY, AND SOCIAL HISTORY



PAST MEDICAL HISTORY

Have you ever had any of the following? (Please select all that apply and use comments to elaborate.)

Illnesses:

Asthma

Autoimmune Disorder (Type) _______

Blood Clots

Cancer (Type) ___________________

CVA/TIA (stroke)

Diabetes

Migraine Headaches

Osteoporosis

Other: ________________________

___________________________

___________________________

Injuries:

Back Injury

Broken Bones

Head Injury

Neck Injury

Falls

Other: ________________________

Hospitalizations: (Non-surgical with Date)

___________________________

___________________________

Surgeries: (If yes, provide type & surgery date)

Cancer ________________________

Orthopedic

Shoulder – R / L ____________

Elbow/Forearm – R / L ____________

Wrist/Hand – R / L ____________

Hip – R / L ____________

Knee – R / L ____________

Ankle/Foot – R / L ____________

Spinal Surgery

Neck: _______________________

Back: _______________________

Other: ________________________

___________________________

___________________________

Medical History Comments: ___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

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FAMILY HISTORY (Please mark X to all that apply and use comments to elaborate.)

Unknown Unremarkable

Mo

the

r

Fath

er

Sib

ling1

Sib

ling2

Sib

ling3

Ch

ild1

Ch

ild2

Ch

ild3

Gender F M

Age at death (if Deceased)

Aneurysms

CVA (Stroke)

Cancer

Diabetes

Heart Disease

Hypertension

Other Family History

Family History Comments: ____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

SOCIAL AND OCCUPATIONAL HISTORY

Marital Status: Single Married Divorced Other

Children: None 1 2 3 4

Other:________________

Student Status: Full Student Part Student Non-Student

Highest level of Education: High School College Grad.

Post Grad. Other: ________________________________

Employed: No Yes (Occupation) ______________________

Dominant Hand: Right Left Ambidextrous

Smoking/Tobacco Use: If current smoker, amount = __________

Every Day Some Days Former Never

Alcohol Use:

Every Day Weekly Occasionally Never

Caffeine Use:

Coffee Tea Energy Drinks Soda Never

Exercise frequency:

Daily 3-4xs/week 2-3xs/week Rarely Never

Social History Comments: _________________________________________________________________________




REVIEW OF SYSTEMS



REVIEW OF SYSTEMS

Many of the following conditions respond to chiropractic treatment.

Are you currently experiencing any of these symptoms? (Please select all that apply and use comments to elaborate.)

Constitutional: (General)

Fever

Fatigue

Other: ______________________

None in this Category

Musculoskeletal:

Joint Pain/Stiffness/Swelling

Muscle Pain/Stiffness/Spasms

Broken Bones_________________

Other: ______________________


Neurological:

Dizziness or Lightheaded

Convulsions or Seizures

Tremors

Other: ______________________


Psychiatric: (Mind/Stress)

Nervousness/Anxiety

Depression

Sleep Problems

Memory Loss or Confusion

Other: ______________________


Genitourinary:

Frequent or Painful Urination

Blood in Urine

Incontinence or Bed Wetting

Painful or Irregular Periods

Other: ______________________


Gastrointestinal:

Loss of Appetite

Blood in Stool or Black Stool

Nausea or Vomiting

Abdominal Pain

Frequent Diarrhea

Constipation

Other: ______________________


Cardiovascular & Heart:

Chest Pains/Tightness

Rapid or Heartbeat Changes

Swelling of Hands, Ankles, or Feet

Other: ______________________


Respiratory:

Difficulty Breathing

Cough

Other: _________________


Eyes & Vision:

Eye Pain

Blurred or Double Vision

Sensitivity to Light

Other: ______________________


Head, Ears, Nose, & Mouth/Throat:

Frequent or Recurrent Headaches

Ear - Ache/Ringing/Drainage

Hearing Loss

Sensitivity to Loud Noises

Sinus Problems

Sore Throat

Other: ______________________


Endocrine:

Infertility

Recent Weight Change

Eating Disorder

Other: ______________________


Hematologic & Lymphatic:

Excessive Thirst or Urination

Cold Extremities

Swollen Glands

Other: ______________________


Integumentary: (Skin, Nails, & Breasts)

Rash or Itching

Change in Skin, Hair, or Nails

Non-healing Sores or Lesions

Change of Appearance of a Mole

Breast Pain, Lump, or Discharge

Other: ______________________


Allergic/Immunologic: Food Allergies

Environmental Allergies

Other: ______________________


Review of Systems Comments:

___________________________

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___________________________

___________________________

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The Neck Disability Index

Patient name: File# Date:Please read instructions:This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage everyday life. Pleaseanswer every section and mark in each section only the ONE box that applies to you. We realize that you may consider that two of the statements inany one section relate to you, but please just mark the box that most closely describes your problem.

SECTION 1-PAIN INTENSITY

I have no pain at the moment.The pain is very mild at the moment.The pain is moderate at the moment.The pain is fairly severe at the moment.The pain is very severe at the moment.The pain is the worst imaginable at the moment.

SECTION 2-PERSONAL CARE (Washing, Dressing, etc.)

I can look after myself normally, without causing extra pain.I can look after myself normally, but it causes extra pain.It is painful to look after myself and I am slow and careful.I need some help, but manage most of my personal care.I need help every day in most aspects of self care.I do not get dressed; I wash with difficulty and stay in bed.

SECTION 3-LIFTING

I can lift heavy weights without extra pain.I can lift heavy weights, but it gives extra pain.Pain prevents me from lifting heavy weights off the floor, but I canmanage if they are conveniently positioned, for example, on a table.Pain prevents me from lifting heavy weights off the floor, but I canmanage light to medium weights if they are conveniently positioned.I can lift very light weights.I cannot lift or carry anything at all.

SECTION 4-READING

I can read as much as I want to, with no pain in my neck.I can read as much as I want to, with slight pain in my neck.I can read as much as I want to, with moderate pain in my neck.I can’t read as much as I want, because of moderate pain in myneck.I can hardly read at all, because of severe pain in my neck.I cannot read at all.

SECTION 5-HEADACHES

I have no headaches at all.I have slight headaches that come infrequently.I have moderate headaches that come infrequently.I have moderate headaches that come frequently.I have severe headaches that come frequently.I have headaches almost all the time.

Instructions:

1. The NDI is scored in the same way as the Oswestry Disability Index.

2. Using this system, a score of 10-28% (i.e., 5-14 points) is considered by the authors to constitute mild disability; 30-48% is moderate; 50-68% issevere; 72% or more is complete.

I can do most of my usual work, but no more.I cannot do my usual work.I can hardly do any work at all.I can’t do any work at all.

SECTION 8-DRIVING

I can drive my car without any neck pain.I can drive my car as long as I want, with slight pain in my neck.I can drive my car as long as I want, with moderate pain in myneck.I can’t drive my car as long as I want, because of moderate painin my neck.I can hardly drive at all, because of severe pain in my neck.I can’t drive my car at all.

SECTION 9-SLEEPING

I have no trouble sleeping.My sleep is slightly disturbed (less than 1 hr sleepless).My sleep is mildly disturbed (1-2 hrs sleepless).My sleep is moderately disturbed (2-3 hrs sleepless).My sleep is greatly disturbed (3-5 hrs sleepless).My sleep is completely disturbed (5-7 hrs sleepless).

SECTION 10-RECREATION

I am able to engage in all my recreation activities, with no neckpain at all.I am able to engage in all my recreation activities, with someneck pain at all.I am able to engage in most, but not all, of my usual recreationactivities, because of pain in my neck.I am able to engage in few of my recreation activities, because ofpain in my neck.I can hardly do any recreation activities, because of pain in myneck.I can’t do any recreation activities at all.

SECTION 6-CONCENTRATION

I can concentrate fully when I want to, with no difficulty.I can concentrate fully when I want to, with slight difficulty.I have a fair degree of difficulty in concentrating when I want to.I have a lot of difficulty in concentrating when I want to.I have a great deal of difficulty in concentrating when I want to.I cannot concentrate at all.

SECTION 7-WORK

I can do as much work as I want to.I can do my usual work, but no more.

.

The Revised Oswestry Disability Index (for low back pain/dysfunction)

Patient name: File # Date:This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage everydaylife. Please answer every section and mark in each section only the ONE box that applies to you. We realize that you may consider that twoof the statements in any one section relate to you, but please just mark the box that most closely describes your problem.

SECTION 1-PAIN INTENSITY

The pain comes and goes and is very mild.The pain is mild and does not vary much.The pain comes and goes and is moderate.The pain is moderate and does not vary much.The pain comes and goes and is very severe.The pain is severe and does not vary much.

SECTION 2-PERSONAL CARE

I would not have to change my way of washing or dressing in orderto avoid pain.I do not normally change my way of washing or dressing eventhough it causes some pain.Washing and dressing increases the pain, but I manage not tochange my way of doing it.Washing and dressing increases the pain and I find it necessary tochange my way of doing it.Because of the pain, I am unable to do some washing and dressingwithout help.Because of the pain, I am unable to do any washing and dressingwithout help.

SECTION 3-LIFTING

I can lift heavy weights without extra pain.I can lift heavy weights, but it causes extra pain.Pain prevents me from lifting heavy weights off the floor, but Imanage if they are conveniently positioned (e.g., on a table).Pain prevents me from lifting heavy weights off the floor.Pain prevents me from lifting heavy weights, but I can manage lightto medium weights if they are conveniently positioned.I can only lift very light weights at the most.

SECTION 4-WALKING

I have no pain on walking.I have some pain on walking, but it does not increase with distance.I cannot walk more than one mile without increasing pain.I cannot walk more than 1/2 mile without increasing pain.I cannot walk more than 1/4 mile without increasing pain.I cannot walk at all without increasing pain.

SECTION 5-SITTING

I can sit in any chair as long as I like.I can only sit in my favorite chair as long as I like.Pain prevents me from sitting more than one hour.Pain prevents me from sitting more than 1/2 hour.Pain prevents me from sitting more 10 minutes.I avoid sitting because it increases pain right away.

SECTION 6-STANDING

I can stand as long as I want without pain.I have some pain on standing, but it does not increasewith time.I cannot stand for longer than one hour withoutincreasing pain.I cannot stand for longer than 1/2 hour withoutincreasing pain.I cannot stand for longer than 10 minutes withoutincreasing pain.I avoid standing because it increases the pain rightaway.

SECTION 7-SLEEPING

I get no pain in bed.I get pain in bed, but it does not prevent me fromsleeping well.Because of pain, my normal night’s sleep is reducedby less than 1/4.Because of pain, my normal night’s sleep is reducedby less than 1/2.Because of pain, my normal night’s sleep is reducedby less than 3/4.Pain prevents me from sleeping at all.

SECTION 8-SOCIAL LIFE

My social life is normal and gives me no pain.My social life is normal, but increases the degree ofpain.Pain has no significant effect on my social life apartfrom limiting my more energetic interests, e.g.,dancing, etc.Pain has restricted my social life and I do not go outvery often.Pain has restricted my social life to my home.I have hardly any social life because of the pain.

SECTION 9-TRAVELLING

I get no pain while travelling.I get some pain while travelling, but none of my usualforms of travel makes it any worse.I get extra pain while travelling, but it does not compelme to seek alternative forms of travel.I get extra pain while travelling, which compels me toseek alternative forms of travel.Pain restricts all forms of travel.Pain prevents all forms of travel except that done lyingdown.

SECTION 10-CHANGING DEGREE OF PAIN

My pain is rapidly getting better.My pain fluctuates, but is definitively getting better.My pain seems to be getting better, but improvementis slow at present.My pain is neither getting better nor worse.My pain is gradually worsening.My pain is rapidly worsening.

Instructions:

1. This is a self-report questionnaire: the patient is instructed to fill it out.

2. The patient follows the general instructions given at the top of the questionnaire.

3. Each section must be completed. If the patient leaves one blank, instruct them to complete the form. It must be completed in onesitting.

4. Each section has 6 possible answers. Statement 1 is graded as 0 points; statement 6 is graded as 5 points. A total score of 50 is thuspossible and would indicate 100% disability. So, for example, a total score of 10 of a possible 50 would constitute a 20% disability.

5. The following interpretation of disability scores is excerpted from the developers of the Oswestry system (457):

0%-20%: Minimal disability

This group can cope with most living activities. Usually no treatment is indicated, apart from advice on lifting, sitting posture,physical fitness, and diet. In this group some patients have particular difficulty with sitting, and this may be important if theiroccupation is sedentary, e.g., a typist or lorry [truck] driver.

20%-40% Moderate disability

This group experiences more pain and problems with sitting, lifting, and standing. Travel and social life are more difficult and theymay well be off work. Personal care, sexual activity*, and sleeping are not grossly affected, and the back condition can usually bemanaged by conservative means.

40%-60%: Severe disability

Pain remains the main problem in this group of patients, but travel, personal care, social life, sexual activity*, and sleep are alsoaffected. These patients require detailed investigation.

60%-80%: Crippled

Back pain impinges on all aspects of these patients’ lives—both at home and at work—and positive intervention is required.

80%-100%

These patients are either bed-bound or exaggerating their symptoms. This can be evaluated by careful observation of the patientduring medical examination.

6. It is recommended that clinicians focus their discussions of the results with patients in positive terms, rather than reportingdisability scores. For example, point out the 10% improvement on a subsequent test.

* Note: in the revised Oswestry, sex life questions were replaced with recreation questions.

Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF-36)

About: The SF-36 is an indicator of overall health status. Items: 10 Reliability: Most of these studies that examined the reliability of the SF_36 have exceeded 0.80 (McHorney et al., 1994; Ware et al., 1993). Estimates of reliability in the physical and mental sections are typically above 0.90. Validity: The SF-36 is also well validated. Scoring: The SF-36 has eight scaled scores; the scores are weighted sums of the questions in each section. Scores range from 0 - 100 Lower scores = more disability, higher scores = less disability Sections:

Vitality Physical functioning Bodily pain General health perceptions Physical role functioning Emotional role functioning Social role functioning Mental health

References: McHorney CA, Ware JE, Lu JFR, Sherbourne CD. The MOS 36-Item Short-Form Health

Survey (SF-36®): III. tests of data quality, scaling assumptions and reliability across diverse patient groups. Med Care1994; 32(4):40-66.

Ware JE, Snow KK, Kosinski M, Gandek B. SF-36® Health Survey Manual and Interpretation Guide. Boston, MA: New England Medical Center, The Health Institute, 1993.

Ware JE, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36®): I. conceptual framework and item selection. Med Care 1992; 30(6):473-83.

http://www.ncbi.nlm.nih.gov/pubmed/8277801





Medical Outcomes Study Questionnaire Short Form 36 Health Survey

This survey asks for your views about your health. This information will help keep

track of how you feel and how well you are able to do your usual activities. Thank

you for completing this survey! For each of the following questions, please circle

the number that best describes your answer.

1. In general, would you say your health

is:

Excellent 1

Very good 2

Good 3

Fair 4

Poor 5

2. Compared to one year ago,

Much better now than one year ago 1

Somewhat better now than one year ago 2

About the same 3

Somewhat worse now than one year ago 4

Much worse now than one year ago 5

3. The following items are about activities you might do during a typical day. Does

your health now limit you in these activities? If so, how much?

(Circle One Number on Each Line)

Yes,

Limited

a

Lot (1)

Yes,

Limited

a

Little

(2)

No, Not

limited

at

All (3)

a. Vigorous activities, such as running, lifting

heavy objects, participating in strenuous sports

1 2 3

b. Moderate activities, such as moving a table,

pushing a vacuum cleaner, bowling, or playing

golf

1 2 3

c. Lifting or carrying groceries 1 2 3

d. Climbing several flights of stairs 1 2 3

e. Climbing one flight of stairs 1 2 3

f. Bending, kneeling, or stooping 1 2 3

g. Walking more than a mile 1 2 3

h. Walking several blocks 1 2 3

i. Walking one block 1 2 3

j. Bathing or dressing yourself 1 2 3

4. During the past 4 weeks, have you had any of the following problems with your

work or other regular daily activities as a result of your physical health?


Yes

(1)

No

(2)

a. Cut down the amount of time you spent on work or other

activities

1 2

b. Accomplished less than you would like 1 2

c. Were limited in the kind of work or other activities 1 2

d. Had difficulty performing the work or other activities (for

example, it took extra effort)

1 2

5. During the past 4 weeks, have you had any of the following problems with your

work or other regular daily activities as a result of any emotional problems (such

as feeling depressed or anxious)?


Yes No

a. Cut down the amount of time you spent on work or other

activities

1 2

b. Accomplished less than you would like 1 2

c. Didn't do work or other activities as carefully as usual 1 2

6. During the past 4 weeks, to what extent has your physical

health or emotional problems interfered with your normal

social activities with family, friends, neighbors, or groups?

Not at all 1

Slightly 2

Moderately 3

Quite a bit 4

Extremely 5

7. How much bodily pain have you had during the past 4

weeks?

None 1

Very mild 2

Mild 3

Moderate 4

Severe 5

Very severe 6

8. During the past 4 weeks, how much did pain interfere with

your normal work (including both work outside the home and

housework)?

Not at all 1

A little bit 2

Moderately 3

Quite a bit 4

Extremely 5

These questions are about how you feel and how things have been with you during

the past 4 weeks. For each question, please give the one answer that comes closest

to the way you have been feeling. (Circle One Number on Each Line)

9. How much of the time during the past 4 weeks . . .

All of

the

Time

Most

of

the

Time

A

Good

Bit of

the

Time

Some

of

the

Time

A

Little

of the

Time

None

of

the

Time

a. Did you feel full of pep? 1 2 3 4 5 6

b. Have you been a very

nervous person?

1 2 3 4 5 6

c. Have you felt so down in

the dumps that nothing

could cheer you up?

1 2 3 4 5 6

d. Have you felt calm and

peaceful?

1 2 3 4 5 6

e. Did you have a lot of

energy?

1 2 3 4 5 6

All

of

the

Time

Most

of

the

Time

A

Good

Bit of

the

Time

Some

of

the

Time

A

Little

of the

Time

None

of

the

Time

f. Have you felt

downhearted and blue?

1 2 3 4 5 6

g. Did you feel worn out? 1 2 3 4 5 6

h. Have you been a happy

person?

1 2 3 4 5 6

i. Did you feel tired? 1 2 3 4 5 6

10. During the past 4 weeks, how much of the time has your

physical health or emotional problems interfered with your

social activities (like visiting with friends, relatives, etc.)?

(Circle One Number)

All of the time 1

Most of the time 2

Some of the time 3

A little of the time 4

None of the time 5

11. How TRUE or FALSE is each of the following statements for you.


Definitely

True

Mostly

True

Don't

Know

Mostly

False

Definitely

False

a. I seem to get sick a little

easier than other people

1 2 3 4 5

b. I am as healthy as

anybody I know

1 2 3 4 5

c. I expect my health to get

worse

1 2 3 4 5

d. My health is excellent 1 2 3 4 5

ACCIDENT/INJURY Q - Chiropractor Peoria IL

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