Concussion Eval Packet

Concussion

Patient Information

First Name(Required)

Last Name(Required)

Email(Required)

Date of Birth(Required)

Social Security(Required)

Sex(Required)

Race

Other

Ethnicity

Primary Language(Required)

Primary Phone

Secondary Phone

Work

Address(Required)

Street Address Address Line 2 City State ZIP Code

Referring Physician(Required)

Phone

Primary Care Physician(Required)

Phone

Primary Insurance Information

Name of Insurance Company

Policy Number

Group Number

Are you the policy holder

Name of Policy Holder

First Last

Relationship to Patient

Date of Birth

Social Security

Phone

Address

Street Address Address Line 2 City State ZIP Code

Employer

Secondary Insurance Information

Do you have a secondary insurance policy

Name of Insurance Company

Policy Number

Group Number

Are you the policy holder

Name of Policy Holder

First Last

Relationship to Patient

Date of Birth

Social Security

Phone

Address

Street Address Address Line 2 City State ZIP Code

Employer

Work / Auto Related Injury

Is this the result of an accident

Date of Injury/Accident:

Insurance Carrier

Contact Name

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Claim Number

Insurance ID Number

State where injury occurred

Employer Name

Employer Address

Street Address Address Line 2 City State ZIP Code

Contact Name

First Last

Phone

Address where injury occurred

Job Title

Job Duties

Adjuster Handling Claim Name

First Last

Adjuster Handling Claim Phone

Attorney Handling Claim Name

First Last

Attorney Handling Claim Phone

Additional Injury Information

Describe how the injury occured

Were you hospitalized for this injury?

Which hospital?

If injury occurred at school/school event, what school do you attend?

Athletic trainer name

Do you have memory of the injury?

Symptoms at the time of the concussion

Unconscious Episode

Fogginess

Dizziness

Disorientation

Headache

Other

What are your other symptoms?

Symptoms after concussion / or at this time

Balance Impairment

Movement Problems

Memory Issues

Nausea / Vomiting

Vision Problems

Disturbed Sleep

Other

What are your other symptoms?

Have you had any treatment for this recent injury?

Please describe treatment

Past Medical History

Do you or have you had any problems with the following? (Check all that apply)

Past Concussion History

Please describe history

Family History

Please check any diseases/disorders that run in your family. Do not include yourself.

What other diseases/disorders?

Social History

Do you smoke?

Packs/Day

How many years

If you quit how long ago?

Do you drink alcoholic beverages?

How many per day?

How many per week?

Do you use or have you used street drugs?

What kind and when?

To ensure we are providing quality care, we need information from you and need to provide you with information about our practice policies. Below are links to our practice policies. Please click on each one to review prior to your visit. When you arrive for your appointment, you will be asked to electronically sign that you have reviewed and understand them.

Forms to be completed:

Policies to view only

Also, please complete the below “New Patient Packet” prior to arriving for your appointment. This information is important for your physician to review with you during your initial visit and if not completed, it may delay your appointment time. You do not need to print. Once you complete and click submit, our office will securely receive your responses.

At Northeast Rehab, we have a team approach to concussion therapy. Our team will work with you to create an effective treatment plan. The goal of concussion therapy is to provoke some of the symptoms while avoiding overstimulating the brain in the hopes these activities will become easier and easier, in essence, retaining the brain. Patient Health Questionnaires are tools used to assist in creating your treatment plan. At the end of this packet, you will be asked to also complete the SOAPP-14 questionnaire. You may be asked to update this information annually or more often as your treatment plan changes over time.

To provide you with secure electronic access to our physicians and staff, Northeast Rehab utilizes a Patient Portal. You need an access code to register. Once you receive your access code, you can click here to register. Through our patient portal, you can request appointments, update your medical history, medications, and allergies, and send a note to your provider. We encourage you to sign up for the Patient Portal before your first visit.

Concussion Eval Packet

Concussion

Patient Information

Primary Insurance Information

Secondary Insurance Information

Work / Auto Related Injury

Additional Injury Information

Hassle Free Appointments

* New Patients Only