Phone: (386) 337-3884

Corrective Chiropractic care for spinal misalignments, postural issues, and sports injuries.

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"I tell everybody about the program because it really works."

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A non-surgical, drug-free approach to severe neck and back pain.

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Auto Accident Form

Patient Information

The information that you will provide on this form will play a key role in determining your ability to be accepted as a patient in this office. Your qualification as a patient is determined by the nature of your injury, the doctor’s ability to treat your condition, your commitment to getting well, your family and/or spousal support, your ability to pay for recommended care, and your willingness to make sacrifices to ensure your proper healing. Please be sure that you answer all questions. Thank you – Dr. Gordon’s Staff.

   Male   Female
   Yes   No
   Yes   No
   Yes   No
   Yes   No
   Yes   No
   Yes   No
   Yes   No
   Yes   No
   Yes   No

Family Health History

Personal Health History

Pain Disability Questionnaire

Instructions: These questions ask your views about how your pain now affects how you function in every day activities. Please answer every question and mark the ONE number on EACH scale that best describes how you feel.

1. Does your pain interfere with your normal work inside and outside the home?
Work Normally
Unable to work at all
1
2
3
4
5
6
7
8
9
10

2. Does your pain interfere with personal care (such as washing, dressing, etc.)?
Take care of myself completely
Need help with all my personal care
1
2
3
4
5
6
7
8
9
10

3. Does your pain interfere with your traveling?
Travel anywhere I like
Only travel to see doctors
1
2
3
4
5
6
7
8
9
10

4. Does your pain affect your ability to sit or stand?
No problems
Can not sit/stand at all
1
2
3
4
5
6
7
8
9
10

5. Does your pain affect your ability to lift overhead, grasp objects or reach for things?
No problems
Can not do at all
1
2
3
4
5
6
7
8
9
10

6. Does your pain affect your ability to lift objects off the floor, bend, stoop or squat?
No problems
Can not do at all
1
2
3
4
5
6
7
8
9
10

7. Does your pain affect your ability to walk or run?
No problems
Can not walk/run at all
1
2
3
4
5
6
7
8
9
10

8. Has your income declined since your pain began?
No decline
Lost all income
1
2
3
4
5
6
7
8
9
10

9. Do you have to take pain medication every day to control your pain?
No medication needed
Need medication throughout the day
1
2
3
4
5
6
7
8
9
10

10. Does your pain force you to see doctors much more often than before your pain began?
Never see doctors
See doctors weekly
1
2
3
4
5
6
7
8
9
10

11. Does your pain interfere with your ability to see the people who are important to you?
No problem
Never see them
1
2
3
4
5
6
7
8
9
10

12. Does your pain interfere with recreational activities and hobbies?
No interference
Total interference
1
2
3
4
5
6
7
8
9
10

13. Do you need the help of your family and friends to complete everyday tasks?
Never need help
Need help all the time
1
2
3
4
5
6
7
8
9
10

14. Do you now feel more depressed, tense, or anxious than before your pain began?
No depression/tension
Severe depression/tension
1
2
3
4
5
6
7
8
9
10

15. Are there emotional problems caused by your pain that interfere with your family, social and or work activities?
No problems
Severe problems
1
2
3
4
5
6
7
8
9
10


Accident Details

Driver  
Front Seat Passenger  
Rear Seat Passenger  
Motorcycle Rider  


Daytime  
Dawn  
Dusk  
Dark  
Dry  
Wet  
Snow  
Ice  


Yes  
No  

Yes  
No  

Yes  
No  


Yes  
No  

Yes  
No  


Yes  
No  


Yes  
No  


Home  
Emergency Room  



Yes  
No  

Please use the figure below and dropdown menus to select the affected areas, type of pain, and severity of the pain you are experiencing

Area
Type of Pain
Severity
1=least 10=greatest
Area
Type of Pain
Severity
1=least 10=greatest
Area
Type of Pain
Severity
1=least 10=greatest
Area
Type of Pain
Severity
1=least 10=greatest

Instrumental Activities of Daily Living Scale (I.A.D.L.)

Choose the option below that best describes your ability:


Operates telephone on own initiative. Able to look up and dial numbers etc.
Dials a few well-known numbers.
Answers telephone but does not dial.
Does not use telephone at all.

Does personal laundry completely.
Launders small items.
All laundry must be done by others.


Takes care of all shopping needs independently.
Shops independently for small purchases.
Needs to be accompanied on any shopping trip.
Completely unable to shop.

Travels independently on public transportation or drives own car.
Arranges own travel via taxi but does not otherwiseuse public transportation.
Travels on public transportation when accompanied by another.
Travel limited to taxi or automobile with assistance of another.
Does not travel at all.


Plans prepares and serves adequate meals independently.
Prepares adequate meals if supplied with the ingredients
Heats serves and prepares meals or is able to prepare meals but does not maintain adequate diet
Needs to have meals prepared and served.

Is responsible for taking medication in correct dosages at correct time.
Takes responsibility if medication is prepared in advance in separate dosage.
Is not capable of dispensing own medication.


Maintains house alone or with occasional assistance.
Performs light daily tasks such as dish washing bed making etc.
Performs light daily tasks unsuccessfully.
Needs help with all home maintenance tasks.
Does not participate in any housekeeping tasks.

Manages financial matters independently (budgets check writing etc.
Manages day-to-day purchases but needs help with major purchasing etc.
Incapable of handling money.

Katz Basic Activities of Daily Living (ADL) Scale

Check “yes” if you are able to do the task independently or “no” if you are unable.


Yes  
No  

Yes  
No  


Yes  
No  

Yes  
No  


Yes  
No  

Yes  
No  

Auto Accident Information Needed




80/20  
100%  






Disclaimer

DeLand Chiropractic & Spinal Decompression complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. DeLand Chiropractic & Spinal Decompression does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.