Advanced Health & Physical Therapy Solutions

Step 1 of 7Personal Information

Personal Information

First Name*

Last Name*

Date of Birth*

Email Address*

Phone (Primary)*

Home Address

City

State

ZIP

Employer Information

Employer Name*

Your Job Title

Supervisor's Name

Supervisor's Phone

Employer Address

Date hired

Employment status

Full-timePart-timeContractorTemp/Seasonal

Injury Details

Tell us what happened — accuracy matters for your medical care AND your workers' comp claim.

Date of Injury*

Approximate Time

Location at workplace

Have you continued working since the injury?

Yes, full dutyYes, modified dutyNo, off work

How the injury happened*

Witnesses (names + contact if available)

Have you reported the injury to your employer?*

Yes, same dayYes, laterNo

Date reported to employer (if reported)

Workers' Compensation Claim

Has a workers' comp claim been filed?

YesNot yetNot sure

Workers' Comp insurance carrier

Claim number

Adjuster name

Adjuster phone

Do you have an attorney for this claim?

YesNoConsidering

Attorney name & firm

Attorney phone

Your Symptoms

Areas of pain or injury (check all)

HeadNeckShoulderUpper backMid backLower backHipKneeAnkle / FootElbowWrist / HandOther

Current pain level (0 = none, 10 = worst)

012345678910

No painWorst

Describe your symptoms

Treatment received so far

Relevant Medical History

Current medications & supplements

Known allergies

Prior injuries to the same areas?

Are you pregnant or nursing?

NoPregnantNursing

Consent & Authorization

I authorize Advanced Health & Physical Therapy Solutions to perform chiropractic examination and treatment as needed. I understand chiropractic treatment carries risk and I have had the opportunity to ask questions. I authorize release of medical information necessary to process my workers' compensation claim. I am financially responsible for charges not covered by workers' comp insurance.

I have read and agree to the terms above.*I authorize release of records to my employer's workers' comp insurance carrier.I authorize release of records to my attorney listed above (if any).

Patient Signature*

Typing your name acts as your electronic signature (ESIGN Act).

Date*

Work-Related Injury Intake