🏥 Workers Comp Intake Form

Palmer Chiropractic Clinic

Dr. Brian J. Bussard • Kent, WA • (253) 854-7700

Patient Info

Health History & Symptoms

Review of Systems & Signature

ℹ️ Please complete all sections as accurately as possible. This helps Dr. Bussard prepare for your visit. Fields marked * are required.

👤 Patient Information

Patient Name *

Date *

Address *

City *

State *

ZIP Code *

Home Phone

Work Phone

Cell Phone *

Email Address *

Date of Birth *

Sex *

Marital Status

Age

Social Security #

Occupation

Employer

Referred By

Workers Comp Claim # *

🏥 Previous Chiropractic Care

Have you ever received Chiropractic Care? *

Yes No

If yes, when?

Name of most recent Chiropractor

1. Reasons for Seeking Chiropractic Care

Primary Reason *

Date Pain Started *

Secondary Reason

2. Previous Interventions, Treatments, Medications, Surgery or Care

Please describe any previous treatments or care you have sought for your complaint(s):

✓

Patient Info

Health History & Symptoms

Review of Systems & Signature

3A. Past Health History

Anticoagulant use Heart problems / high blood pressure / chest pain Bleeding problems Lung problems / shortness of breath Cancer Diabetes Psychiatric disorders Bipolar disorder Major depression Schizophrenia Stroke / TIA's None of the above

Other:

3B. Previous Injury or Trauma

Previous injuries or trauma:

Broken bones?

3C–E. Allergies, Medications & Surgeries

3C. Allergies:

3D. Medications:

Medication

Reason

3E. Surgeries:

Date

Type

4. Family Health History

Cancer Strokes / TIA's Headaches Cardiac disease Neurological diseases Adopted / Unknown Cardiac disease below age 40 Psychiatric disease Diabetes None of the above

Other:

Deaths in immediate family:

Social & Occupational History

Job Description:

Work Schedule:

Recreational Activities:

Lifestyle:

Important: Please complete a separate symptom section for EACH symptom. Start at the top of your body and work down. Call (253) 854-7700 with questions.

New Patient History — Symptoms

Start at the top of your body and work down (e.g. Headache, Neck Pain, etc.)

Symptom 1

Symptom Description *

Pain Scale (0–10):

% of waking time:

When did it begin?

Sudden or gradual?

Suddenly Gradually

How did it begin?

What makes it WORSE?

Bending neck forward Bending neck backward Tilting head left Tilting head right Turning head left Turning head right Bending forward at waist Bending backward at waist Tilting left at waist Tilting right at waist Twisting left at waist Twisting right at waist Sitting Standing Getting up from sitting Lifting Any movement Driving Walking Running Nothing

Other (worse):

What makes it BETTER?

Rest Ice Heat Stretching Exercise Massage Pain medication Muscle relaxers Nothing

Other (better):

Quality:

Sharp Dull Achy Burning Throbbing Piercing Stabbing Deep Nagging Shooting Stinging

Other quality:

Radiates?

Yes No

Where?

Worse time of day?

Morning Afternoon Evening Night Unaffected

Symptom 2

Symptom Description

Pain Scale (0–10):

% of waking time:

When did it begin?

Sudden or gradual?

Suddenly Gradually

How did it begin?

What makes it WORSE?

Other (worse):

What makes it BETTER?

Rest Ice Heat Stretching Exercise Massage Pain medication Muscle relaxers Nothing

Other (better):

Quality:

Sharp Dull Achy Burning Throbbing Piercing Stabbing Deep Nagging Shooting Stinging

Other quality:

Radiates?

Yes No

Where?

Worse time of day?

Morning Afternoon Evening Night Unaffected

Symptom 3

Symptom Description

Pain Scale (0–10):

% of waking time:

When did it begin?

Sudden or gradual?

Suddenly Gradually

How did it begin?

What makes it WORSE?

Other (worse):

What makes it BETTER?

Rest Ice Heat Stretching Exercise Massage Pain medication Muscle relaxers Nothing

Other (better):

Quality:

Sharp Dull Achy Burning Throbbing Piercing Stabbing Deep Nagging Shooting Stinging

Other quality:

Radiates?

Yes No

Where?

Worse time of day?

Morning Afternoon Evening Night Unaffected

Symptom 4

Symptom Description

Pain Scale (0–10):

% of waking time:

When did it begin?

Sudden or gradual?

Suddenly Gradually

How did it begin?

What makes it WORSE?

Other (worse):

What makes it BETTER?

Rest Ice Heat Stretching Exercise Massage Pain medication Muscle relaxers Nothing

Other (better):

Quality:

Sharp Dull Achy Burning Throbbing Piercing Stabbing Deep Nagging Shooting Stinging

Other quality:

Radiates?

Yes No

Where?

Worse time of day?

Morning Afternoon Evening Night Unaffected

✓

Patient Info

✓

Health History & Symptoms

Review of Systems & Signature

Review of Systems — Please check all that apply

Pulmonary (Lung-Related):

Asthma / difficulty breathing COPD Emphysema None of the above

Cardiovascular (Heart-Related):

Heart surgeries Congestive heart failure Murmurs or valvular disease Heart attacks / MIs Heart disease / problems Hypertension Pacemaker Angina / chest pain Irregular heartbeat None of the above

Neurological (Nerve-Related):

Visual changes / loss of vision One-sided weakness of face or body History of seizures One-sided decreased feeling Headaches Memory loss Tremors Vertigo Loss of sense of smell Strokes / TIA's None of the above

Endocrine (Glandular/Hormonal):

Thyroid disease Hormone replacement therapy Injectable steroid replacements Diabetes None of the above

Renal (Kidney-Related):

Renal calculi / stones Hematuria (blood in urine) Incontinence Bladder infections Difficulty urinating Kidney disease Dialysis None of the above

Gastroenterological (Stomach-Related):

Nausea Difficulty swallowing Ulcerative disease Frequent abdominal pain Hiatal hernia Constipation Pancreatic disease Irritable bowel / colitis Hepatitis or liver disease Bloody or black tarry stools Vomiting blood Bowel incontinence Gastroesophageal reflux / heartburn None of the above

Hematological (Blood-Related):

Anemia Regular anti-inflammatory use HIV positive Abnormal bleeding / bruising Sickle-cell anemia Enlarged lymph nodes Hemophilia Hypercoagulation / blood clots Anticoagulant therapy Regular aspirin use None of the above

Dermatological (Skin-Related):

Significant burns Significant rashes Skin grafts Psoriatic disorders None of the above

Musculoskeletal (Bone/Muscle-Related):

Rheumatoid arthritis Gout Osteoarthritis Broken bones Spinal fracture Spinal surgery Joint surgery Arthritis (unknown type) Scoliosis Metal implants None of the above

Psychological:

Psychiatric diagnosis Depression Suicidal ideations Bipolar disorder Homicidal ideations Schizophrenia Psychiatric hospitalizations None of the above

Is there anything else in your past medical history that you feel is important to your care here?

3F. Females — Pregnancies and Outcomes

Pregnancies / Date of Delivery

Outcome

📋 Terms of Acceptance

TERMS OF ACCEPTANCE

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working for the same objective. Chiropractic has only one goal. It is important that each patient understands both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: The adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.

Health: The state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.

Vertebral subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential. We do not offer diagnosis or treat any disease. We only offer to diagnose either vertebral subluxations or neuro-musculoskeletal conditions. However, if during the course of a chiropractic spinal examination we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of another health care provider.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed to others. OUR ONLY PRACTICE OBJECTIVE is to eliminate major interference to the expression of the body's innate wisdom. Only method is specific adjusting to correct vertebral subluxations. However, we may use other procedures to help your body hold the adjustment.

I have read and fully understand the above statements. All questions regarding the doctor's objective pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis.

Patient Signature *

Date *

🔒 HIPAA Notice of Privacy Practices

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. A full copy of our HIPAA Notice of Privacy Practices is available at the front desk and at palmerchiropractic.com/hipaa-notice-of-privacy-practices.

I acknowledge that I have received and reviewed the HIPAA Notice of Privacy Practices for Palmer Chiropractic Clinic. I authorize this office to provide chiropractic care and to bill my insurance for services performed.

Signature of Patient or Representative *

Date *

Pregnancy Release (if applicable)

This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child.

Signature

Date

Consent to Evaluate and Adjust a Minor Child (if applicable)

I, (parent or legal guardian name):

Being the parent or legal guardian of:

I fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care at Palmer Chiropractic Clinic.

By submitting this form you confirm all information is accurate to the best of your knowledge. Our team will review your intake before your appointment.

✅ Form Submitted Successfully!

Thank you! Your Workers Comp intake form has been received by Palmer Chiropractic. We will review it before your appointment. If you have questions, call us at (253) 854-7700.