Hypnotherapy Intake Form

PERSONAL INJURY / ACCIDENT MEDICAL HISTORY INTAKE FORM

(Mark a ✓ on each that applies)

Referred by:   Account No.:   Date:

Full Name:

Gender: M F   Marital Status: Single Married Widowed Separated Divorced   Age:

Birth Date:   Height:   Weight:

Address:

City:   State:   Zip:

Social Security No.:   Driver’s License No.:

Home Phone:   Cellular Phone:

Employer:

E-Mail:   Work Phone:

Employer Address:

INSURANCE / ATTORNEY INFORMATION:

Insured’s Name:

Relation to patient:   D.O.B.:   Soc. Sec. #:

Insurance Company:

ID#:   Group #:

Do you have MedPay? Yes No   Were you at fault? Yes No

Insurance Company of the Person at Fault:

Insurance Company Address:

City:   State:   Zip:

Have you retained an attorney? Yes No

Your Attorney’s Name:

Your Attorney’s Phone:   Fax:

Your Attorney’s Address:

City:   State:   Zip:

ACCIDENT INFORMATION:

Date of Accident:   Time of Accident:   a.m. / p.m.

Your Vehicle - Year:   Make:   Model:

Other Vehicle - Year:   Make:   Model:

Seat Belt: Yes No   Accident Type: Rear ended Head-on Broad-sided

Damage to Your Vehicle: $   Other Vehicle Damage: $

Describe Accident:

ACCIDENT SPECIFICS:

Was this injury accident related? Yes No Auto Work Other

Was this a Job or Work related injury? Yes No   Were you the: Driver Passenger

If passenger, where were you sitting: Front Seat Back Seat

Were you wearing your seatbelt: Yes No   Did the airbag deploy: Yes No

Impending Collision, were you: Aware Unaware Braced Not braced

Did your head: Strike Object Not strike Object Break Glass Other

Did you experience: Shock Loss of Consciousness Whiplash Other

The Weather Conditions were they: Sunny Raining Snowing Foggy

The Road was: Dry Wet Icy   Time of Day: Dawn Day Dusk Night

State your emotions and physical state immediately following the accident:

State your emotions & physical state after the first few days:

IMMEDIATELY FOLLOWING THE ACCIDENT:

Ambulance / Paramedics were called I was treated at the scene

I was transported to Hospital by Ambulance I went to Hospital in my own

I was diagnosed at the Hospital I was treated at the Hospital

Medication was prescribed Follow-up was recommended

OTHER DOCTORS SEEN:

Orthopedist Neurologist Psychiatrist Physiatrist Chiropractor

Acupuncturist General Practitioner Physical Therapist Massage Therapist Other

SYMPTOMATOLOGY:

The pain started:

The pain is made better by:

and worse by:

The pain has the following qualities:

There is / There isn’t radiation into:

There is / There isn’t referred pain into:

There is / There isn’t parentheses (tingling/numbness) into:

The pain is located:

The pain is (as far as timing is concerned):

DAILY ACTIVITIES:

How many days out of an average week do you have pain? >1 2-5 5-7

How much time out of an average day are you in pain? Always Sometimes Never

What are the worst times of day for the pain? Morning Noon Evening Other

When do you feel the best? Morning Noon Evening Other

PAIN RATING:

On a scale of 0 – 10, rate your pain:

0 1 2 3 4 5 6 7 8 9 10

Please use the legend symbols below to accurately mark the areas in which you feel these sensations:
Stabbing/Cutting - ////    Tingling - ****    Burning - XXXX    Cramping - ^^^^    Numbness - NNNN    Dull - ####

Describe the overall severity of the pain:

Mild Nuisance Mild to moderate, but can live with it

Moderate, having trouble coping with it Severe, it is ruining my quality of life

How do the following activities affect your pain?

PROGRESSION:

How is your pain compared to when the pain episode first started? Much Improved Somewhat Improved Much Worse Somewhat Worse No Change

What do you do to relieve the pain?

Please mark a ✓ on each that applies to your daily activities:

Have difficulty climbing stairs.

Have to use handrails to get up stairs, etc.

Have to hold onto something to sit or stand from a chair.

Stay at home most of the time.

Do not do jobs around the house.

Walk slower than usual.

Can only walk short distances.

Have to sit most of the day.

Can only stand for short periods of time.

Stays in bed most of the day.

Change position frequently to try and get comfortable.

Have difficulty turning over in bed.

Have to lie down and rest frequently.

Have difficulty sleeping.

Have to get other people to do things for me.

Have difficulty getting dressed.

Have to get dressed with someone’s help.

Have difficulty bending or kneeling.

Have a loss of appetite.

Have more irritable stages.

What are some recreational activities that you participated in before this current problem and which ones cannot be performed now to the same extent as before?

How often do you have to stop activities and sit or lie down to control your symptoms? Several Times Occasionally Approximately per day Never All Day

List your hobbies & exercise activities

SOCIAL HISTORY:

Smoker Non-Smoker Do not drink alcohol Drink alcohol

How much?   How often?

Do not take drugs Take Drugs How much?   How often?

Number of Children:

MEDICAL HISTORY:

List any medical professionals you have seen for this problem:

List any medications you are currently taking:

List the treatments you have had for your problem:

Chiropractic Osteopathy Trigger Point Injections Epidural Injections

Acupuncture Naturopathy Hot packs Ultrasound Diathermy Massage

Electrical Stimulation Biofeedback TENS Unit Body Mechanics Training

Strengthening Exercises Aerobics Gravity Inversion / Traction Bed Rest

Back Brace Other:

List the types of Diagnostic Testing that has been performed for this problem:

X-Rays C.T. Scan Myelogram M.R.I. Scan Discogram Bone Scan E.M.G. N.C.S.

List Past Surgeries: None

List Past Hospitalizations: None

List previous back, neck and musculoskeletal problems:

MEDICAL HISTORY:

Please mark a ✓ if you have had any of the following symptoms in the past 5 years.

Unexplained fevers Night sweats Weight loss of 10 lbs or more Loss of appetite

Excessive fatigue Depression Difficulty sleeping Unusual stress at work

Unusual stress at home Easy bruising Excessive bleeding Swollen ankles

Lumps in neck, armpit or groin Chest pain or tightness Trouble breathing with exercise

Trouble breathing lying flat Coughing up blood Stomach pain Persistent diarrhea

Change in bowel habits Excessive constipation Dark black stools Blood in stools

Pain when urinating Burning when urinating Difficulty urinating Blood in urine

Urinating more at night Abnormal vaginal bleeding Morning stiffness Skin rashes

Muscle tenderness Persistent eye redness Persistent or unusual cough Joint pain

Dry eyes Dry mouth Swelling

Do you have any current problems with:

Anxiety Depression Irritability Other:

Do you have a home exercise program that you follow on a regular basis?

Yes No

NOTES: