PERSONAL INJURY ACCIDENT INFORMATION

Patient Name: ______________________________________________________________________________

1. Date of Accident: ______________________ Time: ____________________AM or PM

2. Were you: Driver _________ Passenger __________ Front Seat: ________ Back Seat:_________
3. Number of people in your vehicle____________ other vehicle: ___________
4. What direction were you going? North__________South_________East__________West__________
Name of Street:________________________________________ City _________________________
5. What direction was the other vehicle going? North______South_______East_______West_________
6. Were you struck from: Behind_________Front_________Left side_________Right side__________
7. Were you knocked unconscious? Yes_______No_______ If YES, how long _________________
8. Were the police notified? Yes_______No_______
9. Was anyone ticketed? Yes_______No_______ If YES, was it you? ______________
10. In your words, please describe the accident: _____________________________________________
___________________________________________________________________________________
11. Please describe how you felt: __________________________________________________________
A. During the accident: ______________________________________________________________
B. Immediately after the accident: ____________________________________________________
C. Later that day: ___________________________________________________________________
D. The next day: ___________________________________________________________________
12. What are your present complaints and symptoms? _______________________________________
___________________________________________________________________________________
13. Where were you taken after the accident?_______________________________________________
14. Have you been treated by another Doctor since the accident? Yes________No___________
If YES, please list the Doctor’s name and address:________________________________________
___________________________________________________________________________________
What type of treatment did you receive? __________________________________________________
___________________________________________________________________________________
15. As a result of this accident, have you lost time from work? Yes __________No____________
If YES, please complete the following: Date last worked:____________________________________
Type of work to you perform: ___________________________________________________

16. Do you notice any activity restrictions because of this injury? Yes_________No___________
If yes, please explain/ list restrictions____________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

2580 W. Chandler Blvd. Suite #4, Chandler, AZ 85224

Phone 480-498-3991 Fax 888-237-1617 www.serenityhealthaz.com
 PATIENT FINANCIAL AGREEMENT
(Equitable Lien/Benefit Assignment Contract and Indemnification Agreement)

Please read the following very carefully as it concerns your financial

responsibility to the Health Care or Service Provider from whom you are
about to receive services.
I the undersigned Patient hereby agree to establish a lien/assignment of benefits or
claim in favor of Grant Chiropractic and Physical Therapy. By this contract and
pursuant to any state statues that apply in the state where I reside. I give my permission
for Grant Chiropractic and Physical Therapy and/or their agent, to file, record and
serve notice of this agreement (lien/agreement) upon myself and all other parties who
may be liable to me for damages arising from the accident which occurred on
______________ [date], and any subsequent claims arising from this accident for which
I am about to receive health care. I understand that by doing so I have entered into a
contract with the above named health care or service provider. This agreement
authorizes direct payment to said provider from any and all proceeds from any
insurance policy, settlement, compromise, judgment verdict or damages to which I may
be entitled and paid in connection with the settlement of claims or litigation arising from
this accident, in such sums necessary to fully compensate the health care or service
provider from whom I have received care. The lien/assignment created by this Equitable
Lien Contract and Indemnification Agreement shall have priority from the time and date
on which said documents are actually filed, or recorded or served on the liable parties,
over any subsequent liens or assignments of my interests in claims arising from this
accident.
In exchange for providing necessary medical care without requiring payment in
full at the time service is received, I agree to be responsible for all charges associated
with my care, regardless of the insurance companies’ reimbursement, settlement or
compromise. Charges for which I agree to be responsible include any administrative
expenses associated with processing my claim such as charges incurred by the provider
for recording and/or serving notice of this lien/assignment upon any liable parties and
their insurance companies. Also included are any collection charges or legal costs and
fees incurred by the provider while attempting to collect the medical bills related to this
claim should such activity becomes necessary.
I further understand that as part of the process of recording a lien/assignment, I
will receive certified mail with a copy of the lien/assignment enclosed and that this copy
is from my own records and do not require any response on my part.

_____________________________________________ ____________
Patient’s Signature Date
(If patient is, a minor have guardian sign and indicate)

2580 W. Chandler Blvd. Suite #4, Chandler, AZ 85224

Phone 480-498-3991 Fax 888-237-1617 www.serenityhealthaz.com
 PERSONAL INJURY INSURANCE INFORMATION

Name:______________________________________ Date:___________________________

Date of Accident: ______________________ Driver: Yes or No Passenger: Yes or No

Please provide as much information as possible so your case can be set up to your financial
advantage. In the state of Arizona, insurance laws read that you have the right to bill any
insurance policy under which you have coverage. If there is more than one insurance coverage,
overpayment can occur. We only need to be paid once, so all overpayments will be reimbursed to
you after the case is settled.
Primary Insurance: (Your health insurance) we will need a copy of your health insurance card.

Insurance Co: _____________________________________ Telephone Number: _____________________________

ID or Policy #: ___________________________________________ Group Number: __________________________

Medical Payment Coverage: On your automobile insurance, or the automobile insurance for the
car in which you were a passenger, there may be coverage called “Med-Pay”. This coverage is
for any injuries that may have occurred to someone in the automobile. It will cover anything
from an automobile accident that either was or was not your fault, to slamming your finger in the
car door. Using this portion of the policy cannot raise your premium or affect your record in any
way. In fact, this is exactly why you pay for “Med-Pay” in your insurance policy.
Claimant: ___________________________________ Policy Holder’s Name: _________________________________

Insurance Company: ________________________________________ Telephone #: __________________________

Policy #: ___________________________________ Claim #: ____________________________________________

Adjuster’s Name: ___________________________________________ Telephone #:___________________________

Third Party Liability: This is the insurance information for the person who was in the “other
car”. The information can be found on the Accident Report.
Accident Report Number: ____________________________

Was anyone ticketed? Yes or No Who: _________________________

Driver’s Name: ___________________________________ Policy Holder’s Name: ____________________________

Insurance Co. Name: ________________________________________ Telephone #: __________________________

Policy Number: ______________________________ Claim Number: _______________________________________

Attorney Information: Attorney’s name: ________________________________________________________

Firm Name: _______________________________________________ Paralegal: _____________________________

Telephone #: _______________________________________ Fax #: ______________________________________

Email Address: __________________________________________________________________________________

2580 W. Chandler Blvd. Suite #4, Chandler, AZ 85224

Phone 480-498-3991 Fax 888-237-1617 www.serenityhealthaz.com
 1

PATIENT APPLICATION FOR TREATMENT

T ODAY ’S D ATE : ________________ How were you referred to the clinic?__________________________
N AME: _______________________________ HOW WOULD YOU LIKE TO BE ADDRESSED ? _________________
Y OUR A DDRESS : ____________________________________________ CITY: ______________________
STATE : _______ ZIP : ___________ SS #: _________________ H OME #: _______________
Y OUR O CCUPATION : ________________________________________ W K #: ______________
E MERGENCY C ONTACT: ___________________________ P H #:_______________ __
CELL #: _______________
Date of B irth: _____________ Age : ____________ Gender : ____________ E -mail : _______________
MARITIAL S TATUS S M W D Height: _________ Weight: _______ lbs
H OW MANY CHILDREN DO YOU HAVE ? _____________________ W HAT ARE THEIR AGES ? _________________________
T HE PURPOSE OR REASON FOR THIS A PPOINTMENT ? _________________________________________________________
H OW OFTEN DO YOU DRINK ALCOHOLIC BEVERAGES ? ________________________________________________________
D O YOU SMOKE ? Yes No H OW MUCH ? ____________________________________________________
D O YOU EXERCISE ? Yes No H OW OFTEN ? __________ T YPE ? ________________________________
D O YOU HAVE ANY ALLERGIES ? (SPECIFY): ________________________________________________________________________________________________
H AVE YOU EVER SUFFERED FROM OR BEEN DIAGNOSED AS HAVING : ( CIRCLE YES OR NO FOR EACH)
Y N *Broken or Fractured Bones Y N *Osteoarthritis Y N Eating Disorder FOR DOCTOR’S USE ONLY
Y N Circulatory Problems Y N Epilepsy Y N Alcoholism
Y N *Rheumatoid Arthritis Y N Pacemaker Y N Drug Addiction
Y N Seizures/Convulsions Y N Strokes Y N HIV Positive
Y N A Congenital Disease Y N *Cancer Y N Gall Bladder
Y N Excessive Bleeding Y N Ulcers Y N *Head Problems
Y N High/Low Blood Pressure Y N Ruptures Y N Depression
Y N *Diabetes Y N Coughing Blood Y N Tumors
* Explanation: ____________________________________________________________________
________________________________________________________________________________ G ENERAL
________________________________________________________________________________
________________________________________________________________________________
WHEN WAS YOUR LAST PHYSICAL EXAM? _____________________________________________________ I NJURY T YPE :
WHEN WAS THE LAST TIME YOU WERE INVOLVED IN AN ACCIDENT OF ANY KIND? __________________________

MEDICATION LIST NDRA

NAMES NAMES NON- WHO
Rx DATE DATE
OF OF Rx STRENGTH STARTED STOPPED PRESCRIBED
MEDICATION VITAMINS STRENGTH DR. / SELF
D RUG A LLERGIES :
D S
D S
D S
D S S EE MEDS A DDENDUM

D S
DATE: --------
2
ACCT. -----------
PATIENT. ------------------

SYSTEMS REVIEW
In the left-hand column, please indicate with a (C) Conditions you have now or with a (P) the conditions you have
had in the Past If neither apply' mark (NA) ' don't leave any blanks

High Blood Pressure __ FOR DOCTORS'S USE ONLY

DR.
Dizziness/Fainting __
REVIEWED SYSTEMS SYMPTOMS
Insomnia --
Low Resistance -- --- General Weight changes, fatigue, anorexia, weakness, fever, chills
changes in activity
Tension -- --- Skin Rashes, eruptions, changes in warts or moles, pigmentation
Confusion -- --- Head
changes, bruising, itching, hair loss, nail changes
Trauma, headaches, dizziness, light headed
---
Fatigue __
Eyes Change in acuit of vision, use of corrective lensed, loss of
Ulcers -- diplopt<!, phot�p� o!)ia, blurred vis!o°t, scotomata, pa in,
excessive lacnmat1on, redness, disc arge
Eye/Vision Problems __
--- Nose Rhinorrhea, epistaxis, allergies, airway obstruction
Ear/Hearing Problems __ --- Mouth &
Throat
Ulcers, tooth pain/extractions, temporomandibular joint (TMJ),
ain, gum bleedinp, soreness, swelling, enlarged glands, sore
Difficulty Breathing __ flhroat, strep throa
Heart Problems -- --- Neck Stiffness, lumps/swelling/masses, pain
Loss of Bladder Control -- --- Lungs C!)ugh (p_ro�uctive/nonprodu�tive), hemoptysis, dyspnea, pain
with resp1rat1on, wheezing, night sweats
Constipation __
--- Cardiac Palpitations, chest pain, orthopnea, paroxysmal nocturnal
Diarrhea -- dyspnea, ankle swelling, syncope

Digestion Problems __
--- Vascular Raynau(;l's phenomenon, intermittent claudication, hypertension,
rheumatic fever
Nausea -- --- Breasts Self-examination fre uency/results, pain, nipple discharge,
lumps/masses, skin i impling
Female Problems -- --- Gastrointestinal Unusal diet, shspha�a regurpitation, dyspepsia, nausia,
Prostate Problems -- vomiting, belc ing, a domina pain, cramps, hematemasis stool
color cnan es, diarrhea, sonsttpation, change in bowel ha 6its,
jaundice, afy, domlnal swelling
Diabetes -- --- Genitournary Polyuria, nocturia, oli uria, dysuria, uregenc , incontinence urine
Hands/Feet Cold -- color changes hemaflurea, sexually transmityed diseases, d ys-
pareunia, scro1al mass (male), hernia
Hand T remors --
Loss of Memory __
--- Endocrine PolydiP.sia, polY.phagia, temperature intolerance, tremors, goiter,
alopecia, hirsuit1sm, menstration, history, pregnancy history,
dysmenorrhea, premenstrual syndrome, climacteric
Nervousness -- --- Hematopoietic Anemia, abdominal bleeding, lymph node elargement/pain
Sweaty Palms __ --- Musculoskelatal Bone/Joint pain, swelling, joint deformity, trauma, restricted
range of motion, weakness, atrophy
Speech Difficulty __
--- Neurological Cranial nerve deficits, seizures, loss of consciousness, paraly-
Anxiety __ sis, tremors, staxis, loss of balance, numbness, paresthesia

Depression __ --- Psychological Mood swings, depression, anxiety, phobias

lrritablility __

Please identify all facilities/providers you have seen for these conditions and those FOR DOCTORS USE ONLY
you are currently seeing, if any, for your presenting problem(s) D Reviewed External H p
D Release Records H p
PROBLEM LIST D Request Records H p
OR NAME/ FROM WHEN
FACILITY PROBLEM TYPE OF TREATMENT RECIEVEO TO WHEN ExTERNAL Dx'o:

DISABILITIES:

IMPAIRMENTS:
DATE: ------ 3
Acer: ---------
PATIENT. ---------------

PATIENT HISTORY

1. What is your main complaint?

2. On the scale below, please circle the severity of your main complaint (At it's worst)
None Slight Mild Moderate Severe
1 2 3 4 5 6
I 1
I 8 9
3. On the scale below please circle the percentage of time you experience your main complaint:
10 1

1 1 1 1
Occasional Intermittent Frequent Constant
0 10 20 30 40 so Iso 10 so 90 1 100 1°10

4. How long have you been experiencing your main complaint? ___________________
5. On the diagram below, please show where you are experiencing all of your present complaints using
the following letters:
A: ache B: burning pain C: cramping D: dull pain R: throbbing pain N: numbness T: tingling

IJ V

Do you have pain and/or

difficulty performing any of the
following activities: {Check)

personal care _
lifting_
reading_
concentrating_
work

6. When do you notice it most? □AM □PM driving_

How long does it last? __Mins __ Hrs sleeping_
7. What makes it feel better? recreation
8. What makes it feel worse? walking_
9. Have you ever had this problem in the past? D Yes D No sitting_
10. I have □ been hospitalized□ been treated by another chiropractor standing_
D been treated by another specialty provider O never received care social life
for this problem.
11. Have you lost time from work because of it? D Yes D No
Dates?_____ to ______
12. Are you Pregnant? D Yes □ No
Signature: ___________
13. What was the first day of your last menstrual cycle?
14. Number of pregnancies? ___ Miscarriages? Date: __/__/__
 Serenity Healthcare
2580 W. Chandler Blvd., Suite #4
Chandler, AZ 85224

I, _____________, authorize the performance upon myself of

the following procedures: Chiropractic manipulation, hoUcold packs, electrical muscle
stimulation, exercise therapy, stretching, spinal traction, massage, infrared, nutritional
advice and prescription to be performed by or under Serenity Healthcare supervision, or
designated employees, as clinically indicated.
I consent to the performance of other diagnostic and therapeutic procedures in
addition to or different from those stated above, whether or not arising from presently
unforeseen conditions that Serenity Healthcare may consider necessary or advisable in
the course of my health care.
Serenity Healthcare and/ or associates and assistants have explained the nature
and purpose of the proced ures, possible alternatives, the risks involved , the possible
alternatives, the risks involved , the possible consequence, and the possibility of
complications to me.
This office utilizes an "open-adjusting" environment for ongoing patient care.
"Open adjusting" involves several patients being seen in the same adjusting room at the
same time. Patients are within sight of one another and some ongoing routine details of
care are discussed within earshot of other patients and staff. This environment is used
for ongoing care and this is NOT the environment used for taking patient histories,
providing examinations or presenting report of findings. These procedures are
completed in a private, confidential setting. The use of this format is intended to make
your experience with our office more efficient and productive as well as to enhance your
access to quality health care and health information. If you choose not to be adjusted in
an open-adjusting environment, please inform Serenity Healthcare or staff and other
accommodations will be made for you.

I acknowledge that no guarantee or assurance of the results that may be obtained from
the procedure has been given by Serenity Healthcare, and or associates and assistants.
Patient Signature: _______________ Date: __/__/___

Witness: _______________ Relationship: _________

 PRIVACY PRACTICES ACKNOWLEDGEMENT

I have received the Notice of Privacy Practices and I have been provided an
opportunity to review it.

Name ___________________________ Birthdate _____________

Signature ___________________________________________________

Date _______________________________________________________

If you are a minor, or if you are being represented by another party:

___________________________ ________________________________
Personal Rep (Print) Personal Rep (Signature)

_______________________________________________ __________
Description of the authority to act on behalf of the patient Date

The patient named below has chosen not to sign the Privacy Practices
Acknowledgement. This does not affect the type of treatment or quality of care
the patient will receive in our office. We have attempted, to the best of our ability,
to provide this patient with a copy of our Notice of Privacy Practices.

_______________________________________ ________________
Name of Patient (Print) Date

_______________________________________ ________________
Office Employee Title