1636 East County Road E * Vadnais Heights, MN 55110 Phone: (651) 773-9560 * Fax: (651) 773-9546 * Email: Larry@DocMiller.net Name:_______________________ SSN:____________________ Age:__________ Address:_______________________________City:________________ State:____ Zip:_________ Employer:_____________________ Birth date:__________ Home Phone:__________________Work Phone:______________________ Referred By: (Friend)  (Relative)  (Newspaper Ad)  (Yellow Pages)  (Sign)  (Other) Please circle your current symptoms: (Headaches)  (Neck Pain / Stiffness)  (Shoulder / Arm Pain)  (Upper-Back Pain)  (Mid-Back Pain)  (Low-Back Pain)  (Buttocks / Leg Pain)  (Numbness)  (Tingling)  (Stress)  (Sciatica)  (Other:_______________________________) My symptoms are due to:  (Auto Accident)  (Work Accident)  (Gradual Onset)  (Other:____________________________) List Injuries/surgeries in the past Five Years:_____________________________ Have you ever had spinal surgery?  (No)   (Yes):____________________________ List any serious condition the doctor should be aware of:______________________________ Rate your pain:  0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10  (0=No pain, 10=Worst Pain) Previous Chiropractor:_________________ Were you satisfied?  (No)   (Yes) *Females:  Are you pregnant at this time?  (No)   (Yes)  Due Date:_____________ Office Policies:  If I am accepted as a patient at Larry Miller Chiropractic, Inc. I agree to pay for all services, including services not covered by my insurance company.  If I suspend (or terminate) my treatment without the doctor's permission, it will be understood that I have reached maximum healing for my condition.  I then agree to be fully responsible for my condition and future care.  I understand that no medical records or x-rays will be released from this office if I owe any money on my account. Consent To Treat:  I also understand that no cures are promised (or implied) and any risks regarding care at this office will be explained to me upon my request.  I now authorize Dr. Miller to proceed with any necessary treatment.  I have read Dr. Miller's office policies and consent to treat information, and I agree with them by signing below: Signature:_____________________________ Date:________________________ Parent/Guardian:________________________ Date:_______________________ ACCIDENT INFORMATION 1. Date of Accident:______________________Time of Day:_________________ 2. Were you:  (  )  Driver  (  )  Passenger  (  )  Front Seat  (  )  Back Seat 3. Number of people in vehicle?__________  Other vehicle?________________ 4. What direction were you headed?  (  )  North  (  )  South  (  )  East  (  )  West  5. Direction the other vehicle was headed? (  ) North (  ) South (  ) East (  ) West 6. Were you struck from: (  )  Behind  (  ) Front  (  ) Left side  (  )  Right side 7. Were you knocked unconscious?  (  ) Yes  (  )  No 8. Were Police notified?  (  ) Yes  (  )  No 9. In your own words, please describe the accident: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ 10. Did you have any complaints BEFORE THE Accident?  (  )  No  (  )  Yes ______________________________________________________________ 11. Describe how you felt:    a. DURING the accident:_________________________________________    b. IMMEDIATELY AFTER the accident:_____________________________    c. LATER THAT DAY:__________________________________________    d. THE NEXT DAY:_____________________________________________ 12. Have you ever been injured in an auto accident before?  (  )  No  (  )  Yes _____________________________________________________________ 13. Have you lost time from work as a result of this accident?  (  )  No  (  )  Yes 14. Have you been treated by another doctor since this accident?  (  )  No  (  )  Yes _____________________________________________________________ 15. Since this injury occurred, are your symptoms: (  ) Same  (  ) Getting Worse 16. Do you have any activity restrictions since this accident?  (  )  No  (  )  Yes 17. Other pertinent information:___________________________________ ______________________________________________________________ ______________________________________________________________ Signature:_____________________________ Date:___________________