Your Information

Today's Date *

Last Name *

First Name *

Middle Name or Initial (optional)

Date of Birth *

Age

Sex *

Marital Status *

Height *

Weight (lbs) *

Dominant Hand *

Right Left

Social Security Number * (required for insurance filing)

Street Address *

City *

State *

ZIP *

Cell Phone *

Work Phone *

Email Address *

Employer / Company *

Occupation / Job Title *

Spouse / Partner Name (if applicable)

Spouse Employer

Spouse Occupation

If the Patient is Under 18 (complete for minors)

Parent / Guardian Name

Relationship

Guardian Date of Birth

Guardian Phone

Emergency Contact Name *

2

Accident Details

Date of Accident *

Approximate Time

Where did the accident happen? *

Type of Accident *

Rear-end (hit from behind) Front-end (head-on) Side impact (T-bone) Sideswipe Rollover Multi-vehicle pile-up Pedestrian struck Other

Briefly describe how the accident happened *

Number of vehicles involved

Your position in the vehicle

What was your vehicle doing at the moment of impact?

Stopped / parked Decelerating / braking Moving at speed Accelerating Turning Changing lanes

Was a police report filed?

Yes No

Who was at fault?

Were there any passengers in your vehicle?

Yes No

Did the accident happen while you were on the job?

Yes No

Was a company vehicle involved?

Yes No

Was a motorcycle involved?

Yes No If yes, you were the: Operator Passenger

Weather conditions at the time (check all that apply)

Sunny Cloudy Rainy Foggy Sleet / Snow Thunderstorm Hail Other

3

Vehicle & Impact Details

Your Vehicle Year

Make

Model

Estimated speed of your vehicle at impact

Estimated speed of other vehicle at impact

Vehicle damage — describe the damage to your vehicle

Location of damage to your vehicle (check all that apply)

Front Rear Driver side Passenger side Bumper Fender Other

Estimated damage amount

Damage was considered

Minor Major Totaled Awaiting determination

On impact, your body was:

Thrown forward Thrown backward Thrown sideways Other

Where were you looking at the moment of impact?

Straight ahead Rear-view mirror Left Right Down (phone / radio) Up

Head / neck position at moment of impact

Straight / neutral Turned left Turned right Looking down Looking up Tilted sideways

Were you bracing for the impact?

Yes No Partially

Symptoms at the Scene / Shortly After

Did you have any symptoms immediately at the accident scene?

Yes No

When did your symptoms first appear? *

Did you leave the scene on your own, or were you transported?

Left on own (drove) Left on own (passenger) Ambulance to ER Ambulance refused Family member transported me

4

Medical Care Received

Have you been to the ER or urgent care since the accident?

Yes No

Studies performed at ER / urgent care (check all that apply)

X-ray MRI CT scan Ultrasound Blood work None performed

ER / urgent care diagnosis or findings (if told anything)

How long were you at the hospital / ER?

Taken by ambulance?

Yes No

If X-rays were taken, of what areas? (check all)

Neck Mid-back Low-back Other

If MRI / CT was done, area of the body scanned

Was any medication given at the ER / urgent care?

Yes No

Have you seen any other doctors, chiropractors, or physical therapists since the accident? *

Yes No

If yes, list each provider, license type, and last visit date

Are you currently taking any prescription or OTC medications for pain / injuries? *

Yes No

If yes, list them

Have you received any prior chiropractic care (not related to this accident)?

Yes No

Do you have any known drug allergies? * (write "None known" if you have none)

5

Your Current Symptoms

Where are you experiencing pain or symptoms? (check all that apply)

Head Face / jaw (TMJ) Neck Upper back Mid back Lower back / lumbar Left shoulder Right shoulder Left arm Right arm Left hand / wrist Right hand / wrist Chest / ribs Abdomen Left hip Right hip Left leg / thigh Right leg / thigh Left knee Right knee Left ankle / foot Right ankle / foot

Describe the quality of your pain * (check at least one)

Sharp Dull / aching Burning Throbbing Shooting / radiating Numbness Tingling / pins & needles Stiffness / tightness Muscle spasm Weakness No pain

Current pain intensity: 5 / 10

0 — No pain 5 — Moderate 10 — Worst possible

What makes your pain worse? * (check at least one)

Morning (upon waking) End of day Driving Sitting Standing Walking Bending forward Bending backward Turning head Lifting anything Physical activity Rest / inactivity Nothing makes it worse

Have you missed any work since the accident? *

Yes No

If yes, how much?

Have your daily activities been limited?

Yes No

Anything else you want Dr. Jensen to know about your symptoms?

Pain Drawing

required — or check the office option below

There are four drawings below — your back, your right side, your left side, and your front. Pick the letter for the kind of pain, then tap the body exactly where you feel it. Use as many letters and spots as you need, on the drawing that matches where the pain is (pain on the back of your leg goes on the Back drawing). Tap a placed letter to remove it, or drag it to move it. The L and R on the drawings are your left and right.

Body outline — back view — BACK VIEW (seen from behind)

Body outline — right side — RIGHT SIDE (your right side)

Body outline — left side — LEFT SIDE (your left side)

Body outline — front view — FRONT VIEW (facing you)

If you chose O (Other), describe the pain in your own words (for example: throbbing, cramping, electric)

At its LEAST, my pain is (0–10) *

At its WORST, my pain is (0–10) *

Pain moves during the day — these two numbers give the doctor your full range. Halves like 8.5 are fine.

I can’t complete the pain drawing online — I will fill out the paper version at the office. You can also print the paper version and bring it to your appointment.

6

Medical History

Have you had prior back or neck injuries or pain (before this accident)? *

Yes No

If yes, when and describe it

Have you been in any prior vehicle accidents or had other significant injuries? *

Yes No

If yes, describe each one and its approximate date

Have you had any surgeries or hospitalizations? *

Yes No

If yes, list them

Current or past health conditions * (check all that apply, or "None of the above")

Arthritis / joint disease Osteoporosis Herniated disc (prior) Spinal stenosis Diabetes Heart disease High blood pressure Cancer (type below) Fibromyalgia / chronic pain Anxiety / depression PTSD Headache / migraine disorder TMJ disorder Autoimmune condition Asthma / lung disease Thyroid disorder Stroke / neurological condition Other (describe below) None of the above

For Female Patients (skip if not applicable)

Currently pregnant?

Yes No

Last menstrual period (approx.)

Deaths in immediate family (if deceased, cause & age)

Father

Mother

Siblings

Highest level of education

High School Trade School Some College College Graduate Post Graduate

Describe your job environment *

Work schedule *

Does the nature of your job aggravate your condition? *

Yes No

If yes, explain

Hobbies / sports *

Do they aggravate your condition? *

Yes No

Do you exercise? *

Yes No

How often?

Intensity

Types

Do you smoke / use tobacco? *

Yes No

If yes, how much?

Do you drink alcohol? *

Yes No

If yes, how much?

Primary Care Physician

PCP Phone

How did you hear about Mansfield Spinal Care? *

7

Insurance & Attorney

Not sure about your coverage? That's okay — fill in what you know. Nothing on this page is required. If you do not have your policy or claim numbers handy, leave them blank and bring your insurance card to your first visit — our staff will copy it for your file. Our staff will verify benefits and explain your payment options at your first visit. See our Legal Resources page for information about PIP and Letter of Protection (LOP).

How do you plan to pay for care? (check all that apply)

Auto Insurance / PIP (Personal Injury Protection) — Texas minimum Health insurance (Blue Cross, Aetna, United, Cigna, etc.) Letter of Protection / Attorney Lien (no insurance — attorney advances cost) Workers' Compensation (if accident occurred during work) Self-pay / out-of-pocket

Auto Insurance (Your Policy)

Insurance Company

Policy Number

Claim Number

Adjuster Name

Adjuster Phone

PIP Coverage Amount (if known)

Other Driver's Insurance (if applicable)

Insurance Company

Claim / File Number

Adjuster Name

Adjuster Phone

Health Insurance (if applicable)

Insurance Company

Policy / Member ID

Group Number

Do you have a personal injury attorney?

Yes No — I'd like a referral No — not interested

Attorney Full Name

Law Firm

Attorney Phone

Attorney Email

Attorney Address

8

Agreements & Signature

Assignment of Benefits & Contractual Lien

ASSIGNMENT OF BENEFITS · ASSIGNMENT OF CAUSE OF ACTION · CONTRACTUAL LIEN

I, the undersigned patient and/or responsible party, in consideration of treatment rendered or to be rendered and for deferred payment, irrevocably and exclusively assign, grant, and convey to Keith N. Jensen, DC, a lien and assignment of any and all claims, causes of action, and right to any proceeds and/or benefits, including any Personal Injury Protection proceeds and/or benefits, that the patient may have against any other person, entity, and/or insurance company for reimbursement and/or payment of the medical charges incurred, with all the following rights, power, and authority:

RELEASE OF INFORMATION: You are authorized to release information concerning my condition and treatment to my insurance company, attorney, or insurance adjustor for purposes of processing my claim for benefits and payment for services rendered to me.

IRREVOCABLE ASSIGNMENT OF RIGHTS: You are assigned the exclusive, irrevocable right to any cause of action that exists in my favor against any insurance company for the terms of the policy, including the exclusive, irrevocable right to receive payment for such services, make demand in my name for payment, and prosecute and receive penalties, interest, court costs, or other legally compensable amounts owed by an insurance company in accordance with Article 21.55 of the Texas Insurance Code. I agree to cooperate, provide information as needed, and appear as needed, wherever, to assist in the prosecution of such claims for benefits upon request.

DEMAND FOR PAYMENT: To any insurance company providing benefits of any kind to me/us for treatment rendered by the physician/facility named above, within 5 days following your receipt of such bill for services, to the extent such bills are payable under the terms of the policy. This demand specifically conforms to Sec. 542.057 of the Texas Insurance Code and Article 21.55 of the Texas Insurance Code, providing for attorney fees, 18% penalty, court costs, and interest from judgment upon violation. I further instruct the provider to make all checks payable to Mansfield Spinal Care and send to 1600 N Hwy 287 Suite 103, Mansfield, TX 76063.

THIRD PARTY LIABILITY: If my injuries are the result of negligence from a third party, then I instruct the liability carrier to issue a separate draft to pay in full all services rendered, payable directly to Mansfield Spinal Care, and to send any and all checks to 1600 N Hwy 287 Suite 103, Mansfield, Texas 76063.

STATUTE OF LIMITATIONS: I waive my rights to claim any statute of limitations regarding claims for services rendered or to be rendered by the physician/facility named above, in addition to reasonable cost of collection, including attorney fees and court costs incurred.

LIMITED POWER OF ATTORNEY: I hereby grant to the physician/facility named above power to endorse my name upon any checks, drafts, or other negotiable instruments representing payment from any insurance company for treatment and healthcare rendered by the physician/facility named above. I agree that any insurance payment representing an amount in excess of the charges for treatment rendered will be credited to my/our account or forwarded to my/our address upon request in writing to the physician/facility named above.

REJECTION IN WRITING: I hereby authorize the physician/clinic named above to establish a PIP or UM/UIM claim on my behalf. I also instruct my insurance carrier to provide, upon request to the provider/clinic named above, any rejections in writing as they apply to my lack of PIP or UM/UIM coverage. I allege that electronic signatures are not adequate proof of rejection and are invalid to establish rejection, and I instruct my carrier to provide only copies of my original signature regarding rejection as evidence of rejection of PIP or UM/UIM.

TERMINATION OF CARE: I hereby acknowledge and understand that if I do not keep appointments as recommended to me by my caring doctor at this clinic, he/she has full and complete right to terminate responsibility for my care and relinquish any disability granted me within a reasonable period of time. If during the course of my care my insurance company requires me to take an examination from any other doctor, I will notify this physician/facility immediately. I understand the failure to do so may jeopardize my case.

I have read and agree to the Assignment of Benefits and Medical Lien terms above. * I understand I am financially responsible for all services regardless of insurance payment or attorney outcome. *

HIPAA Notice of Privacy Practices

Mansfield Spinal Care & Rehabilitation is required by law to maintain the privacy and security of your protected health information (PHI) and to notify you promptly of any breach.

Your health information may be used and disclosed for treatment, payment, and healthcare operations. For personal injury and auto accident cases, records may be shared with your attorney (with your written authorization), insurance adjusters, and courts as required by law.

Read our full HIPAA Notice of Privacy Practices →

I authorize the Practice to use and disclose my health information for: * (check at least one)

(a) Treatment — to provide, coordinate, or manage healthcare and related services (b) Payment — to obtain payment for services, including auto insurance claims and personal injury billing (c) Healthcare Operations — for quality assurance and practice management (d) Legal / Attorney — to share records with my personal injury attorney

By typing your full name below and checking the required boxes, you certify that:

All information in this form is accurate and complete to the best of your knowledge.
You have read the Assignment of Benefits / Medical Lien and agree to its terms.
You have received the HIPAA Notice of Privacy Practices.
You understand this typed signature has the same legal effect as a handwritten signature.

Patient Full Name — Digital Signature *

Date *

Parent / Guardian Name (if patient is a minor)

Relationship to Patient

I have read and agree to all the above. I authorize the disclosures selected above and acknowledge the HIPAA Notice of Privacy Practices. *

Privacy note: This form is transmitted securely via HTTPS. Do not include credit card numbers or unrelated financial information. Questions before your visit? Call (817) 477-2907.

Every field marked * must be completed — the form will not submit until they are. If a question does not apply to you, type None or N/A.

Dr. Jensen will review this before your first appointment.

Accident Patient Intake Form

Your Information

Accident Details

Vehicle & Impact Details

Medical Care Received

Your Current Symptoms

Pain Drawing

Medical History

Insurance & Attorney

Agreements & Signature