Welcome to Catskill Rehabilitation and Sports Medicine
this form.
Name __________________________________________ Age_______ Date of Accident_______________________________
Please take the time to respond to the following questions.
Chief Complaint(s):
How did your problem(s) originate? Have you had similar problems in the past? If yes, when? What types of treatments have you had?
Medical History: Please list all previous accidents, sports injuries, fractures or work related injuries.
Surgical History: Please list / include dates.
Medications: Please list all you currently take. Please include all prescription, non-prescription as well as vitamins or herbs.
Allergies to Medications? Please list and include what happened when you took the medicine.
Social History: Married	Y / N	Divorced	Y / N	Right or Left handed.
Do you smoke? Do you exercise regularly? Do you have hobbies? Would you describe your diet as healthy? Do you sleep well? Would you describe yourself as spiritual? Additional Comments:
If this visit is a result of a motor vehicle accident or a work related injury, please continue answering the appropriate questions. If not, please give this paperwork, along with your insurance cards to the receptionist.

Motor Vehicle Accident Patients Only
Where were you sitting?	Were you seat belted?
Did you lose consciousness?
Did you sustain cuts, abrasions or contusions?	If yes, where?
Did you anticipate the accident?
Were you clutching the steering wheel?
Did you bang your knee?	If yes, which one and on what?
Did you bang your shoulder?	If yes, which one and on what?
Were you evaluated in an Emergency Room?	If yes, which one and when?
How did you get to the hospital?
Were x-rays taken?
Were medications prescribed?	Please list names.
Were you given a neck collar, knee brace, or crutches?
Have you seen any other medical doctors, chiropractors or physical therapists?                  If so, please list.
Have you ever had physical therapy before this accident?               If yes, please describe when and why.
Have you ever had chiropractic treatment before this accident?                If yes, please describe when and why.
Have you ever had acupuncture treatment?	If yes, please describe when and why.
Since this was the result of a motor vehicle accident, please skip the next section and go to next page.
Workers Compensation Patients Only
Employers Name:
Length of time employed there:
Job Title/Description:
Describe how the accident/injury occurred:
Where did you first go for evaluation of your problem? (Please list all nurses/medical doctors/chiropractors/physical therapists, if any, whom you have treated with for this problem prior to visiting Catskill Rehabilitation and Sports Medicine.):
Have you had previous injuries of a similar nature?                Please list any/all previous work related, motor vehicle, sports related or other injuries.
Have you ever had physical therapy before this accident?              If yes, please describe when and why.
Have you ever had chiropractic treatment before this accident?               If yes, please describe when and why.
Have you ever had acupuncture treatment?               If yes, please describe when and why.
How do you injuries impair your ability to perform your daily activities?

Motor Vehicle Accident Patients and Workers Compensation Patients Only
Before Accident - BA Post Accident - PA
________ Headaches	________ Morning Stiffness
________ Ringing in Ears	________ Digestive Problem
________ Difficulty with Concentration	________ Shortness of or pain with deep breath
________ Poor Sleeping	________ Hearing Problems
________ Depression	________ Jaw Clicking/Pain
________ Difficulty with interpersonal relationships	________ Memory Problems
________ Difficulties swallowing	________ Anxiety
________ Difficulties with urination	________ Constipation
________ Eye Problems	________ Sexual difficulties
________ Dizziness	Other: _______________________________________
Have you had x-rays?               If yes, where and of what?
Have you had MRI's?               If yes, where and of what?
Please use this space to describe any other issue which may assist Dr. Scheinfeld and the team of Professionals at Catskill Rehabilitation and Sports Medicine in alleviating your problem(s).