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98-05587
01 I'; ,. d', " " " Ii " Ii L.. jJ, dl OJI -Jdl )-1 I I , I , ! i .,,, 'i; " i{' .1' If, " I' 'I' .," " ,-I; 'ji' 'j: i), " 'il " "'; ,,;I " I' " L ~ ...,... '"r W Ji It " " , " '" , (i Ii ',j .. ",;r, " ,I 1~!;lif~Y "'i'l_ ,-i;J' " --,!-',- '" '1" Ii' 'f, ''''( J', ''\ ) I ,-I f " I' " " I" Ii '!; ;i i' Ii " U 'i /i " ,-" ,Ii " ,,' "" 'I; Iii " ... y " i " Ii 'i' I " " , , 1 'i , " , " ;' , , 'iJ , " I' " " , " 1 , i ,,' ( ~' It -I 31" &; LO, lC) I obi CTi I I ~I ., ji " 'i, fi ji 1<' " f' "Ii 'i, " ,," :1 " ,t. " ;; ." , FRANOi:8 Fi:Pi:RIOO,i:YI.i:R Ewl . RONAI.P I:Y~I:R,' Pll1lnllffa . IN THi: OOURT OF OOMMoN PI.I=AS OlJMI3i:R~ANP OOUNTY, PI=NNSYI-VANIA olVI~ ACTIoN - ~AW . No,; 98-6687 OlVI~ y, PI=~ORA8 I3AI<I=R, PefllnQl1nt JURY TRIAl. Oi:MANP!:P ffiAlilllfliE.QB..WJJHgB.l\WAb..Qf....A~r-I;ABANQg TO THR PROTHONOTARY, .. Plel1ae w/tIlQmw the I1ppel1mnoe of Amy 0, Foerater, Rsqulre fie l1\1orney for Oefen'll1l1t, ",I , Pelorl1a 131111er, 111 tile ElPoye 1T1!1\1er, . " HARTMAN & MII-~~R, p,O, ';} I / l3y: . ,/11' '!'(J,'/J. . ' Amy 0 Foerster, !:squlre '1{,/l A\lorney I,P, No,: 77986 126:128 Walmlt Street Harrlspurg, PA 17101 (717) ?32,3046 PRAECIPE FOR ENTR'LQ.U~ TO THE PROTHONOTARY, /, PleE1ae enter 11113 ElppeE1rE1l1ce of Stephen 1:, Geclulqlg, Rsqulre, E1S E1\1orney for Pefenqant, PelorE1a l3E1ker, In tile E1Pove mE1Uer" ", " . PE1ted: :60200,1 2 /t7h r I THOMAS, THOMAS & HAttER, I..I..P l3y: /~(~~ Stephen 1:, GedUlqlg, I:aqulre AUorl1ey I,P, NOil 43630 , 306 N, Frollt 81" 6"1 Floor p,O, (30)( 999 Hmrlabllrg, PA 17100-0999 (717) 237-1119 /, . " ,/ " " " "I' '0 i' " " " " ,. I' ,I 'I " 'i IL " j.' !' 'J. . .' 'I '0 '0 j. ,:- l' "; n '" ,f! II " f' " !I " " ii' " ,', !' ' " Ii " " " " I, " ,I '; " ." " , " 1', 'if " 100 " ".. " '1< q'i ["J' " " u1 <~O \(.) ;"1.: 'il I' :LI " '11'g" {-J " :~(lJ " f.) , Illl", ""j J.,'j ,/I. ,1"'1'0 "i'). ;.'.) "':1"u " ,e, r;" I ~,q .,~t; ,. " I' " " 10 10 if; 'I. I " I' " " " '!' " " .. " " I' ". 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JoIYI ,lilH nl1(1 IWNAJ.,D \iIYL,I':H, Plnll\l:l!: I'll IN 'l'llioJ i,:OtlR'l' Oi" COMMON 1'1,1;;1\8 "CllMI1\!lIHIMID COllNTY /l'ltlNN8Y roVl\N H\ I 1 , I 1 , I , v, "CTVlI, I\C'l'ION " I,^W NO, [Hl-[i[ill'l c1y.i.l j)\iJI,OHMJ HTlKlm, po !:<)))dnl\t JllI,y 'I'H11\I, \J1;lMANP\,lP '1'.Ll\..1l'lTIE.!!'A " _L\lliU'.t:lLl\TLQlL.Ml~MQJilllli)lJM T, hlC!l:fl' On March 1", 199'} / ,I'ln.\ Ill". 1 E I' l'rf\l1CJBf.l ["E.1d8l:1oo"li1ylqr Wf.\," 1n:II.\I:8(1 11'1 a 'J:E.1aJ:"el)el motor veh1olo i\ClCil.elont on '.\'r.I.nc11.8 Hoi'\c1, 1\8ar the l.nt:erfJoClt10n 01' 'I'r1ne110 Rond nnc1 Bpol.'t.l.n9 Ill11 !,onci, TIt' the" ,. t+me oe the acoldent:, Mrs, Fedorloo-Rylo~ was operating i\ Honda, tl.'avGHpg ear.~t on' 'l'd.neUo Road, Mnl, [1'Bdod,()o,l!;y~pl: bro\1uht her vel)l,ole to 11 stop beld,ncl a li.n'" oe trafHc Btoppodnt a rGd Ught, 'l'he Defendant, opornti,ng i\ Bulok, oolli,decl .l.nto the rllar ue MrB, !'ec1ed,oo- myler' B I'ltat::l.onclry veh:l.ole, 'l'lje property, c1amC\ge to the l:m\1: oe MrfJ, !;'Gder!,oo" myler's qondC\ wC\s very m:l.nor, I\tl:C\ohed [\13 li)xhibit A arc' Clolot:Oop:l.es of photogrl1phfJ dep1ot: 1.ng the rem: 0 E MI:a, Jo'ederl,co - mylllJ:' s Iloncln', 'ilhe c;\nma~le to tho r1ght rear qual.teJ:pan~1]j 113 (ron1 t1 pdOl: \11o\:or veh:l.ole . acoident, 'I'he only noU.oeabhl damago to the rear of: Ml:S, !~ederl.oo" b1yh1r'13 Honda /'IB i1 ]:'('113\111:.0[:. \:he .Maroh 1'1, ).99'71 1.9 to thB right: rear b~(illper, 'l'ho bumpol: wml' b\lfJhec1 for,ward, J!ilj]n/i'MJ .1 " " I' I' ", I' I ' H " " " " lj I' .' " "ii " j, .j' 'j " .' " " II" " j; " " . ~ ' ";, ".; " " .' " " " I, " ;1 I' I' w, 'I I' 11\ j' " ., ;f H 'i ,;:" " ;if i/,: " " i' I I. j, i : t'., I ~ ' I II 'I I ! I ;1 ,I I' " " Ii " , " 'I . , ' ' " II, " " I' 1', .)1 Ii " " " " ': I ~ I I I \ ~I I I ! ~l' I ~ " 'I " ", ,I;' "H II I. p " " " I, !. 'j' " I: (' " ,," " ",'.t; ,. .' " q: H ,. ,. , , . , , 'I. ;In" 'l I, ." ;Ii " " it ," 1', " ,.1' I' " 'I Ii 'I, -j, I, "11 ,,;1 " ,. " ')' " f'j" ,I, " " I J. I 1 I' I Ii ,) ~ " I. I , I , " kll! : I' I I , i, " III 1"1 , , F IflQNAh INJURY Q~lg~TIPNNAI..~ Nonl0' 0~/-}n('(;S ~)tiX(Jt) ~!;,k::c-PO'O of Inhlry-~4uj(; ~J:~ I'tlPno~2&,.] "rz,f // ,Acldrllua ~. t:':> Iq'/)~,(}(l(lti.-(ill Olly-1.~(!J(.')jf2:J:.!f!- ~IOIO~-~I(XnO {~ ~mployor'u Nomo .L:L(.L ,~,.......,___.___~ r:mployor'u Mclrouu .J.1J!!Lh..-,-I:J1. __" ,Yo~r Il1u. 00, ~q., '---" __.____ POllay II /IoUI1\'u Nomo prlvor/Olllo! Vohlolo ~,-- Ina, 01;1,,--__-,- polloy II-- ( ) Yon 1'lr.N11 Nomo ' -::--.---,--'--.-r-:---- ( , I You ( )rtl Nornu(s) ___---,"___-.,..__ ". , NATURIl of AOOIPIlNTI/\./L_ ' 1, Dolo 01 AQolclonl,.,-$~~ Tlmo 01 Pay -S.:~), I~!i ' g,,\^Ioru Yuill " (~/IVor ,,( ) Pooounoor () Fronl Sool () aoeKflool, .,. ~, Numbor olpeop'lo In yuur VOhIPlo?__L.----'-_~~__ Olher vehlelo? --J ,I, WI101 dlroellol1 woro YOUI)eO"~d? . (>6;0~~, ,(') ,:~--;. ( I SO\lIl1' . ('; Wonl , ,on (l1omo olalreol) ......JS{~Ms-,T-;::z......:~,L:}--.:..L:::"JL?:c,(( ))1) /-.. QI.., 6, Wh~1 dlruellon Woo 011101 vohlolo hooc/oel? () Nonh (I gosl I I SqUlh . yr:0eol on (llama ofi~lroel). ~.:5.q'}'d:Le......... 6, Woro yuu olruak froml" ( I f;Jolllnel I) Ilronl () \..111 side 7, Woro you knooKad uh.oonsalous? . ) Vao ;"-1,10,"" 0, Wore 1'01100 'noll/IOcl? i)(Yoa (I No " ,~. In your OWI1 WOlds, plonso elene/lllo oool,'onl: ~Z/:7/;)J,)e~11 J1'--A:!tJ1ZiiLJ.l.:1-L-'?i.9/c. Ie: (~J\" L-.,y-' -t1? /. Jll ILL) 5 P rJ 1'/L /1 /1-fl?-. ':7.:IL~iJ?-I;c.';"":ll .:TrY) ~ /7? /.1 (",~~(.~':H.~'-'1) -,J2/.1Lk...:f)~~ I'll'" /W..:1D ."'I'J 14}r:J<Tt- 1i:l#'fd...a1p.71/~ '1_", < :-fel.. r'v') , . ')L11 1..+6..= ----r= h~L{! [) ....:....WQ:5-b.t+. (J}'l.E.,11') HI;' " . . .' , ""-.'/"Sli'Jt 10, Dlel you Ilova any phYolool aomplolnlo DEFORE THE AOCIDENT? ( ) Vas \ ~o. If yao, plaooo closorlpa In.dalallr . "Iova YClll roln'n~clllfl o\ICl(llOY? Warn lhara any wllnouaooe? r- " " '\><(R'IOhl ald~. . " II yan, 101 hQ'IIlonu? ' " '" ,I" II. Plooaa dooarlba how you fall: /'( , / " a, DURING 1I1a ooaldonl: -..LLJJ.q~~ ' ,. 'MM'DlA"''''''''h"''"'''''''' ~DI'5'1'; . ') 0, [ATllR THAT PAY: _.J:I:..f!..jf} /) I-J.c IIJ::.. )i .~,. ta~ ,(').L)ci.I "f'q/ ,1- d, THENEXTPAYI /-/r.:,1(/ P.;{JC ;./ I~ / A..'(JcL 1'/411!'7 12, Whal ura ydlU Pt\ESgNTcornpl~'rll~ /Hld ayrn(llom~? )?(..~('.l' I ;Q.A~'. rn 1/1/,'jr )71'/ 1'-71> i.1 ,';.. t. /. . '.. ~.~ l. ) ~ 11~' h (.) (I<} ,II " , . " ,1.\ " POCTOR"PAT'~NT RHATION~HIP IN Cf-lIROPRA~Tlc ' INfcmM~p CON~~NT "I: " .. QmmrRi\mlC1 ' . .. IIIG 1111"I10rll\l\1 In n\=knpwlnduo tho dlfforon~o 11,61W,I1UI11ho hOAII,h aAnl ~, pOl1lAhloa of chlmpr1\l:lIc, OGtopp\\\hy nm1 mo\lIl1lno, C llroprncllc Iwnlll1 cnro GllokG 10 rOG\orll honllh Ihrol18h nAlllrnl I11llnnG wllhoql Iho \I~oof moq clno or G\lrtJl1ry, Thla UIVIlG Ilwbolly mAxhnlll11 ppporlllnlly III \1\11I?-0 lis Il1horlml rllcllpornllvu powors, TI\p G\jCCPGG uf Iho " chlrl1prncllc IloClor's procodllroG pf!ol1lloponth 011 onvlronmllnl, \11]110, rlylns CO\lsua, plWGh::nl nl1(~ Gplnnl!:ol1lll1lona, II Is Imporlnnl 10 IImlllrGlnn\1 whAt IllllXpocl frol11 chlropfi1allc hlloll 1 CArll sorvlcos, . . . ^N^I,Y~la . .. , A \Ioolor of chlroprn\=,\lc condllclG II \=l1nlcnl nnAlysls for tho oxprllGG P\lrposo of dOlo, nnll1hUl, whol,hor Ihoro I"G flvl- Ilon\=o pf VortobrAI ~llllllxAllon8Yl1\1romo (VSS) or VorlolHnl Sllhlllxnllon compluxos (VSq), Wllon sllchVSS And vsc CPll1plOXlla mil fr.l\md, \=hlrPprAc\lc ml/llstmo'1ls IInd nn..lllmy procoqllros Inoy bo 81von In on M\omPI 10 IPS lore splnnlln,lewlly." 1\ Is 11\p, chlroprncllc prom Sll Ihnl spin III AII811,I110l1t nllows nerve ,tromm,I5slonlhrolls lout Iho 10dY Ami slvoa 1110 body All opporlllnlly 10 usa lis Il1horol1l rOCllporollvo pnwors, plllllo Iho oOll1plexll\lls of I1ntllro,no do\=lor CIII1 prpmlsp YOIl spoclflc rOSlllla, This dopol1ds IIplln 1II0lnhoronl rllcllpornllvo powers of 11113 bOIly, ;, I i' PIAONOala .. .. ... . . Allho\IRh Ifpclora of chlroprnclI\= nro oxports In \=hlrorrAallc dlnSI.1Pslsl tho VS~ nnd Vsc, thoy /HO not Il1lernol rlledIGnl~IJoGlnllsIS' r:vory chlrpf1,roatlll pollonl ~hq\llt homlnd(\!1 or h s/hor pwn sY,mPtom& Aml~ho\lld ~o\=llrp olhor opinions f hofsho hAS Any \=pnaorn ns tolho nol\lro Qf hls/llOr 10lnlaoncHllon, Your doctor ofGhlroprilc;l1c mny oxpnlii nn pplillon AS 10 wholllor or pol yO\! sho\!ld tnko lhls slnp, but YOIl ",0 rosponslble for tho nl1AI . do\=lslon, . . . . . ' .; ,I' JNroltM~P ~oNSr:NnOH ~HmOllRi\CTIC CAIlr:, . ... . ^ pAlhlf11 In comll1S to Ihp doalor pf chlrolJfOctlc, Illvoslho dpclor porrnlsslol1 anti mllhorlty 10 cora for 111Il pnllont . In nCGor(Jnnr.o with Ihl3 chlrplirnGtla toslS, tlosnosls and onolysls, Tho chlroprACllcl\cllllstmol1t or 0, lhor c1ll1lcnl procodllres nro usulllly bononcl~1 and suldom CAlISO any probloln. 111 fOrO Gl\uas, undorlylns physiCAl qofocls, Ifafor- , ml\lus, PI' pothqloSloa mAY rondor Iho ,pnllol1t susaopllblo to Il1lmy" Tho doctor, of cO\lrSO, wllll1Pt siva A Ghlroprnc. till, ndJlI~lmonl, or hOAlth CArO, If holsho Is oWArU IhM ~11\=h cora IMY bo GOl1trnll1dlcolod, I\snl111 It Is tho rosponalbll. Ity oflho pnllol1\lo mAko It kl1OWI1 pr to loom Ihrollsh boohh cmo procodllrea wholovor ho/shels sufferlr\s froml . lolont potholoslcol dofpcls, 1I1r\oa,sos{ or do(ormltlos whIch IVollld91horwlse not pomo 10 .thon\lill1l1ol1 of Iha doclor o,f chlroprnGlIc, Tho p,ollU,I1\ should look 10 lho corruct apoelollsl for Iho proper dlnsnostlenl1cl cllnlcnl procedures. Thu doctor of chlrorroctlc; prnyldos 1\ spoclnll~od, I1PIl-dupl,lcnllnll heoltl,'~ervlce, Tho doctor of chlroprnallc Is . . "lIconaod In 0 speeln prnctlco ond la nvolloblQ 10 work wllh olhar lypoa of providers 111 ypur heAlth cnre rlls me, llr:sU~T~ ., Tho Illlrposo of chlroprnGtlc aorvlaosls III promoto nnturol hoolth 'hroush Iho redllcliol1 of the VSS or vse, Slm:o thoro oro SO mnl1Y varlnhlos, It IH dlfnclllt tp prodlot ,he limo schodulo or llf11cncy pf tho chlrtlproctlc proeodurea, Somo\hnoa the roapOl1ae Is p \onomol1ol. ' .'. Inmost c<1aoslhoro Is 0 mora srndunl, bill '1ulto ~lIlIsf"cloIY rnspol1sn, Occnslol1nlly, tho roalllta '1lro le~s thnn oXIJoctUtl. TWO, or 1110ro slmilnr aOlldlllol1s may ruspond dlfforen,\IY 10 Iho snmo chlr,oproGtlc cora, ,Mi\IlY modlGf\1 folmos find qulGk rollof throus ,chlroproclia. In turn, wo mllst ridmlt thot conditions which do not rllapond 10 chlrollrActlo coro lnny GolnO 1I11dor Iho control or bo halped thrpu8h modlenl scion co, .1'1)0 fncI Is tbAl thu salence . of ch roproctlc ond nlo\Hell1o moy neVor bo so OXoct os 10 provldo donnllo nnswors tp nil problems, !loth hnvu , tllnUo sreol slrldos In ollllvlnllns pllln nnd a~nlrolllns dI500~0, TO THIll'AmNT Plooso discuss Ol1Y quos\lol\s or probloll18 with tho doclor before 51sl111\s thla slnlQll10nt of pClllcy, I hnvo rond, nnd ,1ll1dotslnl1d tho (or081)1I1S, ' , - DATE ,,'/ ././i.',.... " ~J .~ \ .. \ - . ' ,', I I / J~.' /)' .,,-" '1").1" ".-1 I ,.... ~ ", _~~A:Ut~:__ ,./__. ,~ .. .. .f" 01190, \". riM, CI"I*_ nll"'"" I'""",,,,,, r.'tf//J'<l.lJrnc.\m " ~i AfifillHf/oll(fn Allll Itl&TmH;rIUtll'lln 11I1I1~ln I'AYI1HIH , I' " ,H. QI;tl~I\^" oFFH:r: PIll,ICY MmtlM~tlT OF III(tlr:Fmll hl!l'llhyin~tl'\tP~ M1Qdl1'uot thl! ~ In~\tl'~np\l comppny to Ppy 11~,OhPok I\1llCle o\li p'1lll1\Pl1o\lllll'ep\;ly tal lI~nll clllflOI'IVlr.TIC CI.INIG, ?70~ MIlliKin sr" GAM" 1111-\" "" 170B I IIPl'pllY 11~~lgn plll\1odlo~l Il(lI1Pf1t~ to whfc:hl Pili Pl1tHled to \;I1l! 1101'11 CI11t'Pill'lIctlo" 011~io ps PPYlllont tOVl~1'11 thl! tot~l cl1~ruos for pI'ofl!ssionlll ~al'vicp~ rOl1d\1l'oll, This . 15,11' (,Iil'ect PS~iijnll,lont Of, l\1y.rights ond Ilol1pfjts lindoI' this policy, TI1,1& psslonl\1pnt will ral\1pin ill affaot \lntil ravokod hy 1\1~ In writlng, A photocopy of thl~ psslgnl\1ont is to lIe (Jol1sidarod 05 Volid liS 011 pl'1gil1l11, 1 UllPr:nSTAtlIl TlIIIT I, AM F!NAlHHAI,I.Y I\r:SI'OH~tII~r: Fol\,^~h GII^,!lH;~ WIIHTIlr:n on NOT flAlIIlIY SAW Hi~UI\^HQr:, I, ha1'pllY "lIthol'l~e sllld psslunpe tarole,,~o pll informo(;ion 110COS~orY ~o ~OCllrP ~ho PIIYI\10I1t, s"i(1 infol'IIHltipn mpy 110 r~l~"sElII tOil1slIrpnc: Gr,l~rJ~:/ylj\lsto,I" PI' ~tt~rn~.!.nvo1Vo\~11 tl,~'~' PIIsO, /: ' PATHI ~_ C., '..... I/;_ ,SIGNATunr: 1.--\ -:1.((.:(/(. -. (1'....1.1... .I " - r . I :.',.. '. . 1"/ , , . ,. ar:Nr:IlAI, OFFIOr: POI.ICY h Itis YOllr 1'0spol1silJilHy to, 1>11,1' lIflY IIdd1tl 0,11111, cQ~t~ not covol'od by YOlll' lns\II'III1Ce. V,1tllmlns IIl1d 51lPpllos 111'0" to >0 pllld 1'01' whun thoy lire I'ocolved, '?. It 15,1'0\11' 1'05ponsil1ilHy to koop this offlco IIlhto-dllte,col1col'nlng IIny chlll1gos In yOllr addross, 1l1slIl'lInco COVOl'lIgo, ro)octlol15 by inslIrllnco, otc., " , ' , 3; You Pl'O dfroctlY ros~onslI)lo to PIlY 1'01' YOlll' cloductlb10. j, ~, 'Paymo"t 110t I'ocoivod 115 1ndlclltod 1'/111 bo collectod from II co.1'leQtlon Pgol1uy. and ,1'0111' ba1anc~ wllT h8 j~cl'oased by the og0l1C108 fOeS tocoVOI' thalr costs, , ' 6. This office l>11ls YOlO' inslll'anco liS P cOlll'1;osy to YOll. alii' plltlont" Ho I'osorvo" the rlght to rovoKo this pl'lvlledge fOI' pl'oblems aCColll1ts,. , , . .. O. If YOll do not have lnslIrlll1ctJ coverago. YOll may pay fO.r tl~oatmol1t by cash1 choCKl " Vlsll ol:f""st~I'cal'd, Payrool1l; 15 dllo lit tlmo of 50l'vica, If a monthly 1>111 119 ollt on 1s,l'oqllostod...1t must bocol1fll'mod \'Iitl' the lJ1l1111g dOpllI'lmel1t, " " , ANY QUESTIONS ,OII,YI!OIlLI(MS CONCEI!NIIHl YOUI! 11ILL SIlOUI,IIIlI~ lJlltECTlill TO OUIl IlmItlu IIEPAIITMENT. ., ..'" " " , ' PIA~NQelE! aHJ:J:T 'pA'I'I~N"'f;1 NAMJ:" ~:h'<.'t--I1(':'.l..~/~;t'rf!.~-I-;:~~~ ~Z;/d,"""&Al'J:agp 2 2199a iltiFlVIOAt. I , W!M11Aa~AQ.f.~Q!LIAO\, & COOCV/< f!tl, Oarvloooranlal8yndroml! "I!I!,I! PlepI11011mrm\ ollnlorverlelJfll1 cflee ~o O~rvlal1l PIsc synclrpmll 71!4,6 PI\lOrclqrs(lfll1\l L\lm~08119rl1l pr 81\Qrolllpa !'lBV Plll'Vlpobraol1llllSyndromo Jolnl . 'f?g;l OarvloalMVIlI\l111 7af1.70 urwpeolflecf PlscrdorlOoqoyx t1~, Oervl01110111 71!4:f1 1'lypermo\11l11Y 01 ooooyx '-'fg~;1l ,Oarvlpal NaUral\lll1, Neurllle, 7af1.4 Ne\1tlllll or'Al\cIlO\III\ls, ~ump06!1arl\l Raqloular NeWal0111 P4-r\!-,. 60lalloa, 60111110 Nllurllle I 7;3tl,l\ Oervloal Plscrcfore,13r!1ohllll @i,I!___J ~\I01llIlOo, (loW Pl10k pain) NalJrlll1l or Rllcfloulllle 7i:!ir.1 Plepll\aomanl 01 Lum!Jnr In\orverlellllll Oervlol1l Plaxus OOmprllllalol1 Plso wlo Mvelop!1lhy 0,. omprall~lono, r aplnlll NelYo Ilpo\., , tlfitl,4 Lu01!Jflr Plexue Dl!lOrder Oeryjo!lITMlaollle 846,0 ~ulnPflr !3praln$\rriln Oarvlol1l Myofl10olllll nU!,10 Prolapaa, Prolrualol1, Auplura or oervlol1l SP~lf1I:tyloale Hamll1l1on of Plso Oarvlol1l NeUfllVallQull1r Compression 7a9,5 Inllo01mllllon olllle Hip Joln\ . OalVlofllSprIllnlSlraln 7i:!4,oOlheLe. Unspeolllod Dlsorders/aook Qarvlolll PIIlQ Synclrome 8ll9,0 supluxpllon OetvillOoranllllSyndrome 'f2i:!,p2 DegenarElllon 01 ~um\1ml\..umposaorElI Oaganllrllllon of CalVloE\llnler' InlelVer\apnll (lIllQ vel1ahral 01&0 a5(1,p, 71l4,9 7~a,5 7!'lIl;e 738,4 aaa,9 Q47,O 7g2,0 7i:!e,g 72i:!,1\ :rHOFlAOIO ~ PElln In Tll0rE\010 Spina 7i:!g,11 OlaplE\Qamal1l of Thoraolo Inl, Plsc 724.4 Naurlllsor Alldloull\lsTl1oraolo 786,5 Ohaal PElln 7e6,0 Dyapnea 785,1 Palpl1!\lIona tl5ll,1l Nerve Roo I Irrllp\lol1/0agol1erallol1 722,51 Oagenerallon ot Thoraolo Inl, Disc ' ~I!E. ,/ WRIeJ'. HAND ANn F1NGER~ I, \l59,1l Inl~ry 10 Wrlal 955,4 Il1jUty \0 Hand' . 955,0 In \Iry \0 NaIVe In Hancf or Wrlsl ll57,2 Oorral Tunl1el Synctrollie 642,1 SpralnfSlrp1n of Hahct A!ili1.li , FOOT AND TOEa 951),7 Il1jury 10 Ankle or Fool 645,0 Spraln/SlrElII1 of Ankla 7i:!1l,7 Oaloaneal Spur ' . ll55,5 Tarsal TunnalSynctrome OTHER 706.2 Qactwet\ll1g '729,82 Mel1atrual Paln/Oramps 6i:!1l,4 PMS 780,61 InsomnlE\ 787,0 (31 Complaints 112,5 OUl1dldl\ 9n5,1l AllergleB, UnapaQllIad 693,1 Food Allarglell 737,0 Ourvu\Ure of Spine 019,0 V!rsllnfeollon, Unepacllll1d . 477.9 Respiratory Allergy 712,0 AI1hrllla I, 956,1 8rrlin~losla 1161,1l H alai atnla Ma,o Sinus. 719,1\6 Pain In 1..0War ~eg 644,8 Sprl\II1/Slraln of I<naa or ~eg SHOULOER AND ELBOW !:lllll, g Iil!Ury \0 ShoUldar' . 1l96,3 In \lfy to l:lpow . . 726,tl SynovlUs, Buraltls, & TanoanoVllla (:Ibow 726,10 aynovllIs, aUfsltls, & Tenoanovl\la Shoulder OTHEIl . . 030,b 717.9 780,7 41lB,Il 702,3 340,9 1 au.4 47b TMJ SubluXEllloll Paravar1ebral Myolnaollls rallgue AsthtnP, aronohlal !ida/nil Mlgraltle Hepdaohea 'Vartl(jo (Neuropathlo) OltzlneBS ""IUatl~p HERD CHIROPRACTIC CLINIC, P,C, ~7011 MAnKEr SlIlEH I CAMP IIlll, PfNNSVlVANIA 170\1 (71717J7'1681 fAX (7'7173101646 MUtUUl.LP..illill.ngaflIil!illlI' PAT'~NT, r f\1lJY\.t:..i.o '2Y,Q.Clin-L'CP t~0~ev\..--"', PAT~ OF nll~ mWOflT\ QOT 311995 THt: A130Vt: OAPTION~P PATIt:NT: If la under aallve ol1ro, . , tHla \leen relaasod Irom oaro, "., , haa reQohud Q alale 01 mnxlmum medlonl Improvomonl lor Ihls opndlllol1 andlllls bean roloE\Qecl Irom QOllvo oara, l'le/She hns beel1 ndvlaeej 10 relilrl1 011 nn as neeejecl bllsls lor Il1a aonlrol of PQln Mc,l eXQOarlHlllons, . THIS IS NOT MAINT~NANCf:: OAR~. HISIH~R OONDITION AT THISTIMr:: "I ;I''''''-IS Im\>rovlng wllh 'Iho presonl oourso ollroall11el11.' rElma nil slallo, " Is relrogreaalng, , IINTr:RIM AGGRAVATIONS OR AOOIOf:NTS: ("1:: eXlended slEll1dlng, sllllng or al'~oPll1g, . ( YhOllsohold diltles, ' ( .-)/ dillies appurtel1E1nl 10 1110 pnllon\ 's regulf\t employmenl. () Qlher(plo!\se epaolfy) "'':: PReSENT SUl3JEOTIVl= OOMPLAINT8:----!-Li2f / ~~l(' 64- /.J-d-e.'L~ ,. . " I' I..' flROGNOBIS:-d.~, ' TREATMENT p~ Tl1le pallonlla 10 be seall ~ week(a), nnd wllllhal1 bo ro-ovEllllnlad EIfler -"'. '--0 IIrne(a) EI week for Ihe next , dllya lor his/her eXlsllllg healll1 slalus, l !,! The Ilallel1llells 1101 dlaablod Irol11 Work al Ihla lime beoEluae 01 this Il1lury. " ! 1 , I. \ GEflALO M. bINOUBR, P.o. I:'.,. SSN 100'44.4403 IRB' . 113.1111091111 I' , '''', \, I.' / ~. HE.RP CHIROPRACTIC CLINlc;~ He, ~704 MAnKE! SIRm ICAMP IlIll, PIN,NSYlVANIA 17Pll (717)737"681 FAX (717mlol648 . MilllTHLVPlIPG REeS . ~~f10R'( f1A'fll=NTI \-'~:J f\.(!./YL(:t-D '--':?;',t,clULc:e-C:' ..-E~(LWL' .' PAT~ OF nlls R!!PQRTI NOV 3 01S95 " " " Tl-Il: A130YR OAPTIONf.P PATIf.NT: (~I~ uneler nollve Cara, () hils been relensecllrol11 Onre, () 11116 rel\oheq n alnlo 01 moxlmWI1 meellool Improyemenl lor Illla C0l1eflll(J11 anef has tJeen releElaeq . from aOllye oare, HelSllo 11as peen a(JvjseC,llo relllrl1 on an aa neflelecl baala lor lhe 001111.01 01 pElln nl1el oxaoerballolla, Hils IS NOT MI\INTr:NANCF. Cf\Ar:, HIEj/l'IF-A CONPITION AT TlI18 TI~m: ( ~Ia ImproYlng wllll Ihe 'proaonl oourao of IrOallTlel1\. () rern<llna alalia, () la rfj\rogreasll1g, IINTF.AIM A~QRI\VATIONs OR ACOIPf.NTS: iL (,-( extenqeef stanclll1g, sltlll10 Qr stooping, .. , (..-l;>llouaellolct qullas, ... .. (,') clUllaa nppur\annnl 10 Iha"pallal1l's rsgulal ornploymonlo (, ). Olhet (plei\se apeolly) PRESENT 8lJI3JE~TIYr:COMPLAINTS:-::;2/'I!'.-<d~; d.-'\1l I' '! ~6r " --- '. ,(' PROQNOSIS::6_K'V\..-\ , TREATMI:N1' PLJ\N: Tills pallenlls 1~ he aoDn -,--.", .lfine(a) a ~eek for the next, 'I II , I' Weak(lI), <lnd Will Illal\ bo ro-eYi\luatacl tiller li,-daya fat hla/lleroxlalll\g health attltu~. " Tile ptlllehl lalla not clleatJleef Iroll1 Woile at Ihlallmo tJ~oauae Qf this I"jury, QERALl) M. lllNoHafll b.o. aa.~ 100.44-4403 mal 11[1.211 DllQB" " , ,. ,'" ') ,.' ; I. I ~ f-IERP CHIROPRACTIC C~INIC, PIC, a70l1 MAlIKH smm/ CAMP "Ill.. I'~NNSVW^NIA 17011 (7171737,1661 FAX (717/.731,16116 . . Mllt:crJl.L..'L..Ilf:lQ.!lUL;!lJL.filliillB! . PATIt:NTI.. . '-"~? /la~0l-CU) L'7J.et{e.~_t.(:. u- E,~,(UL, PATt: OF Tltl~ Rt:rORTl .JMI:J 1. Igg~ ' \. . TI-I~ A130YF. OAPTION~P PATIf.NT: I ,(;Il UIHlar flotlvll Pflre, .' '.. . '. .. .. . l hlls ~alln. rala"se(j frpm Ol\re, , '" . hfls raaahe(j " 1l1E\le of mQxlmum mac1laflllmproVamol1llor this oonelltlpn 11l1cj hE\s poan relal\sacj 'rpm I\pllve alire, He/She has 1>0el1 advlllec1 10 return on IIn as l1eecjeef pE\alll for ItHl aontrpI. of p<lln I\nrJ l1xfloerpntlof1ll, THIt'lIS NOT MAINTf.NANCl: OARf.!. HISn'If.R CONPITION AT n'lIs TIMf.!: (~n'll IIn provln 0 )v(th the preaent ooursD of IroQtlnent.' .. ( relnelne statio, " . ( Is rDtrooresslno, , IINTf.RIM AGQRAVATIONS OR AOC/OF-NTS: ' " (f(~ eX\~nc1ecj staMlno, sllllng or stoopll1g, , ,. ( LhoUSllhold dUlles, . ( ((jIHles appurtDn<lnt 10 1110 pnllent'a roglllnr eh1ploymol1t, ( Ollw (plense epllolfy) , .. . ., PRESENT SLJaJr:;OTIYl: OOMPI-AINTS: . /?f,;A /~-I-'VL- " ... I ,I I '.' PAOQNOSIS: '-eLv'-.' .. TREA'rMt:NT pJN: 'rille pallent 'a to be seen _ week(s), ancl Will thel1 be te-aVllluotDd Illter \, ,'I tlmo(s) 1\ Wee.k for the rieXI , , clnYIl lor his/her existing heallh stAtue, 'The patlel1llsllll not cllsl\plllQ /tom work at this lime peoauao.6(thls H1j\Iry, .ii. . ", tlaRI\LO M. lJlNOHElR, 0.0. .. sa, ,1~Q'44'44oU I tIS, 211-1I1101121l, ,: , " " . I, \ I;'~"I'~"I"'.':W! i:A',:,..,t:',I" , J ", ',,~', '.~,\.,,:,','. '" ,I'.', ,1'/" , . " .. .,. II'~ ..1......J.I..,."lh Lj "1'!I' " '", ,. "I .... ",.,.., . ...1.., ""'" .. .,.." , ' ., 'j'l' " ., 1'1 I,t" " . . I " I \ " ' 1":.0 l.l.'. ),i.,,1.,\,~;, 'f .', <"I'" 't\ t,,' ,,', ..... 1,\-, ., , ' , " .'It,"-,I,"" ' I" '., "'l"" 'I' . .'" .\, , . . .10 ".,.., , "'.I)~I""\"ll""""\'.~' ~.'''''..'' '" ...'il" , '~;"" , "'," "'\"';0111'0 '1 ,. "',, " ':~';d.i;W '~l~$~i'*' iliU;t t ~~'I'i~mYl"'\:il'~IIU\iijUl"l\ hl"i:ii(' ,V;.!' ".,.. . '14fJ,\;\V:":i.!"I:;',".!, .i'~ '11:" ",.: ", "'''':>il '" II \",,''':\\ '"jn':!il''''' ~""'llt,l~nl'\ 1/',., 11.. \l~ ~ ,.1, \"1 ,'" I, '" I'.,' '" n'\ 'f', ""'j"I"'I' '~I,..",.".,.f\,jl' ..," '1",1" I U -'lc"'"" ,,' ' "\'. ,,~ t n-." .1 l' \ j J \ ,'.' \,' I ~ \ 1 I' \ , 't,' II' ,I iI', 't(, ., ", : Jl,. \ '11"" \ ' , , "r ..\,( '1) ~K" J'1",...,N.' ;V,!..t,}, ,/" r' ":1' ".,"..""..,.. "'" II t,l,\.)",,, f' ",.,,, ' ' ,'., , '; 1 'I Ij I" I;' ,I' ~ !\' 1.\ 'r ," ""II' ,. I ,'I 'I" l I, I' f'. " ",."..t.."j;''1,..,.,(!,!ilAl''ll'' [~~'jl"JI':"".1. "''',,,,'10,,,,,,,,,,,,,,'':',1',11, , ' fJ.,.1,l Ir'" " , ' " 1\1" 61,~I'I"l'1,1:1. ,~~ :({", . " . ,1' """'~ . :~.~ '. ' . "'I' "I' 111t,1.' '0.,1,' 1.'" " " C' I' , ',l,~' . "I \,' ,', "IL', .' "It" , , , , ' ,",'i ,.." "i "'. .1 I ' " .'" ",f'" .1".'1\'....."..,.."., 'I" "I'i/' 4'\"'."'" '11'/ i ....' .' '.', . I, . ,',"',' ~', ;:";,~"'" ,I I' j HERD C;HIROPRACTICCLINIC, PIC, ~70'1 MARKET smm I c;MP 1I1~l, PENN5YWA/'iIA 17011 (7m m.166i f~ F!7l7J1'loI16 " " , ~ONT~LV PROGRESS Fl~flQfiI ..,';:....'.::'.." , ,;,'."',1\"" .. , '.. ....,.., "., "'J" .. ~ '" . :"'iVl!\!i,f;~(~~.~~t~l~fi~~ }!,.,:;,:,,: ;,.:"':i "', \n ~\I"I i~H~ 1111.i!:">\'",,,, ',1, '.,' .. 1,1. \ , t~t...~.:,'t.,., I" , ,,' "\"""\ ""t",,,,,,,,,,).., '. ". ~l~ gt, ~" "'., '''I . .1 . "",' '11M' (J(I.I,. ",,'..., 1 Ii 1'" . I '" ,I,:.{..,;,'\' ." : , ."1,'.'.1"., , . ,';"(,i:;\' . '1,1"',"';'" .... , ' .\/. ',~' , .,~ f1ATIf;NTI PATr; OF .THIS Rr;PPRTI ~tA/!UUjlJ 1r~ H. o/~LJ . MAY ~ ~, 1996. TH~ AI30Vf. (JAPTION~P PATI~NT; (11' un~er 1I0llve OllrO, . . , ( . hllll PElIlI1 rElhHIseq from oMe, . .' , . ( IHIIl rfll\ohect II 11\1110 of maximum mectlollllmpravomenl for Ihlll aonctlllon IInq htiw peen relEHIllo(j from l\allve Ollro, Ho/Bhe hila peol1 IIclvlaeq 10 relum 011 QI1 lie neoctocj Pllalsfor Ihe oonlrol of pall1l1l1ct eXlloEHlJl\tlons, .'. THIS 16 N Q T MAINTr:NANOr; OAR!:: HII3/H~R CONDITION AT THIS TIMf.: " " " (l III Improving 1'11111 Ihe 11roaol11 OOurSEl of troalmon!. ( relnlllhs Slllllo, " ( ) III relragresllll1g, . II NTI;A 1M AqQf1AVATIONB on AoclDeNts; I eXlen(joq Illl\nctlng, al\lIng or a\ooplng" . haUlleholel elUt!ee, ... . elUlles IIppur\el1l1nl 10 the pllllenl'a tOOlllllr empioymef1\. ) Othllr (plllallo speolfy) . ' PRf.BI~NT BUl3JliOTlve COMPI-AINTEl:_ '- .-.-.. ....,........~....~"..... ,...... ''''.-' ..,. ..,~~.". ,.. ...........-...."'....... "'''h_.., no. .._, .... 'i\;" .. , .."_.,,......,,~~.~...-.. PI'IOGNOBIS; Tf'laATMENT PIJ\N: This pallel1lla lobs seen IlIne(a) 1\ weok lor the nexl _ , week(s) ,lInct Wllllhen be ta,evaluated after elays for hllllher llxlsllll0 he'alth etl\tua, , ThEl pillion! Islle' nal ellBebleel from work at IhlB time booQuae 01 this Injury, , '''' ,,,. .,,, , '.., ,\., ;h~,'\"," 11',',",', . . ."'~' II,'" . , . ,:t.,., '. 'I:.~',,, 1..1.1I"~"~I.i,'I.H.!... , ' . . " : l~llf\~~t.~I~II~:*-.~,~..,L:.: I'. .' '. '., .' ,\1 ;,', ,j ..' yo. '.'~':,~~ , t;b~;I:' DIQH~R;'b.lf.~." ,.":;' :'," "ss; ',JoU:;f4~14iiB ',""'::' .'fll~,:,~':.:i1~~~ffo9rlli..;':. , '.\I"'lI~Lj[,' ". (", ", ""''',''''''''''.'._, . '. ".", "" , , ';'~;""'/I~ll~,~,~,.~,:,-,,"itt P.,,,','.. ' ." ""I\.".~". . /"'''''; i":it'i':"{'~\:'~'~"'" ..: .....~ "'-1.-~~.__...~:---__~_... "'.: .' ..:r,....---'.--...I----.~J/.t..._~_""'-'.......U."":'"''---'-~_-; HERD ClilROPRACTIC CI.lNIC, PIC, ~70'1 MARKH slnm I CAMP IlIl(, PlfINS'ILYANIA I7nll (717) 137,\661. fAX (111)131'16'18 , MJJ.NIlibL PRO 0 Ilf. B 8 Fl ~ I!illlI . , " PATlt:NTI JQr1Cvltf.l'..D 0:t?LQ,1.I_Ci.l PATt: OF TtHfl nt:PPRTI . ~U'" 311998 EJQe,'L- ( . , . THe Af:lOYl: CAPTIONSP PATIf.NT: l",,)-IS unqer l1ollVo. Q1\ro, ' . . , IH\8 peen relel1sed Irom onro, ' . l 1111ft rel10had 11 sllllo of mflxlrnum mOdloQllmprovomol11 for Ihla oondlllon nl1(1 hfl8 hoon rolallsed . Irom aqllVo oare, HelSl10 has \loon IIdvloo(1 10ro\llrl1 on on 06 noqdod hoala lor 1110 oonlrol 01 pl1ln IInd ,axaaorhl1llona. HilS 18 NOT MAINTf.NANCE: CARS. I:IIS/HSR CONDITION AT THISTIMi:: " , " , l..-rls ImproVI110 Will, Iho proaonl oourao ollraolmonl'. ) roml1lns slalla, .. ) Is relrogresslnQ,.' " IINTl:RIM AGGRAVATIONS OR AQUIDENTS: Vr~X\end!ld sl11ndl,ng, 81111110 or slooplng, l ~r - housohold dulles, r dUlles aj.1put\onanl 10 1110 pallonl'a rOOlllor ornploymel1t. Olhol'(ploasa speolfy) PRESr:NT 8Ul3JEOzr VI: COMPl-.i\INTS:-.-ej/~I. c:;;.~&.~, _-6~.cl d c.'. I ,. {f.-, ti!,),uI>, ~'.~ 1.-, _---P.':!:~(/#./ ,C:; _c..I~lW~ ,1/''1--'- ,; 6'.1114'> ; '. . (I t7'-~r- 7' ~\t..L- c..(-,\",.Jl~Z,~,vf.. . .. , . , . ~ROGNOSIS: ~:l . .. . l/' TREATMr::NT PLAN: This pall ani Is 10 bo aeon .I,i\ G!l.r'~'~~ 'i:(../!..~,pf(/ 401"" . ~. . .' ," I " 1.\ 'I' I I( . I. I' ~ i.,! 'I,,:: IImo(a) a Woak lot Iho noxl week(s), nnd Will 111011 bo re.uvnlualoq, nllor _ __ duys lor hla/har aXlallng health status. , The patlan\ la/Is 1101 dlsnblocllrol11 W()rk al this \llno bQ~nuile of Ihla Inlury, , '),' , al:Mt,b M, blNoHen, p,O, aSII HERD CHIROPRACTIC C~INIC, P,C, ~704 /j1ARKElsmm I C, AMP 1I1~~1 NNNSVWANIA 17011 (717) 737.1661 fAX 1717) 73"1646 MmlItlb.L.llfHlillH:SS ~gpJlli.T. '" PATI~NTI .---0(t1Ufl-tW -0 e,c.Le..,\-(.ClJCCL1Qt-'I-- PATIlQF. TIlle ~f,PORTI .. AUG ~ 11996 ( . TH~ A\30V~ OAPTION~P PATII:;NT: '1 ~/Is I1nllar Elo\lVfl ollra, . . l hall paan ralaElsacl from cElra, . . ... ,,' hllll reaohed 11 slala pf m!1Xlrnul11 rnadloQlll11provamonl for \Ills oOI1(llIlon lwlhas Peel1 rOI\lllaocl trom lIollve alire, He/8ho IHIS peon udvlsecl \0 relum on UI1 Ela noo(!flcl Peals lot the oon\(ol of pElln l\f1Cl oXt\OorPfI\lons, ' THIS IS NOT MAINTGNANOG OARG, HISlll,GR OONDITION AT THIS TIM!:: 1 ) ~Ia Improving wlll1 Iho prosonl oourso of Ireulman\. ' 1~ rernl\ll1s slallo,. . . la relrograssll1g, " liNT GRIM AaGI~AVATloN8 OR ACoIDENTS: r( aXloridod sllll1dlnu, sl\\ll1g or S\O~:Pll1g, v1 household dUlles, . . ....)' du\lell UppU!IIWH1\ 10 Ihe pllllol1\'s regulm employmal1\, ) Olher(pleuse apuolly) PRESGNT 8Ul3JGOTIVE COMPlAINTs: " /lJ (.'e!/:i. . I'?~\j I' PROGNOSIS:_-t:-, ~~.' TRIEATMI:NT P~N: Thlaplltlenlla to Po aoon week(s), .lInd will Ihll11 be ro.evulllllted nfler tlmo(ll) II Wook for \lIe l1exl _ cloys for his/her existing hOElllh stll\ua, Tho pEl\len \ la/ls not d~Sl\blad from Work ulll1ls tlmo bo~nus of Ihla 1I1)ury, . r:J cJN.- .J;--;/J PI CJ41..4A.,,"v/.5 ~JM 1'-,,1 n.td,l~ v.....f,,,"v ("0 t.. " i/. I ~',",~;; " al!nAl.p M, OINOHan. p,o, SSII ..100-44-4403 mall ~tl-l!11 0926 , HERD CHIROPRACTIC C~INlc;, P,C, ~70'\'MAnm smEET /CAMP Hill, PHINSVWANIA 170\' ' " (717) 737,1611 FA:<(7171131,16<l8 ' MilllIl!U-J!IlllilB E S S R lillQRI i-',\ TIl:~1T1 ", \' I,", II '11 . ~ ....J ,~.. .L.,..... .' "1 I,'" I ; ,.. (,...,.. ..I, .'(.. " ';:J;\l~,I...-..' , ! \ OA,~ OF II'lIs RliPCRT: JAN'~ J. I~);"I THE: ,",SOllF- O,\i'TIONE;) ?,c..Til:~IT, I \ , ) :9 'In\1ar ar,I:'I'l ~"r~ nas aeen r~.ea:'e~ from Gare. -,,3 r~3'~~'l~ :, ,I~a\'l ?I "'~,O~1um ma~loal 'mc'~'19""'l0110r \1115 canCllllan O\nrj has ba~" 11316!laeCl ft~ ';1 a..::Ll, ~ ::l(;-'3;'S..,:~ "'as. ::S~I' a':'I'S~': '1: ';~~'" :jn ,~n as "e-3~~'J, -=aJIS ler 1n~ ~~n','.l .,:)! ':,\.;' ana :),In;S':)9.1:0ns. -:.'.2 S ,\I:J,t I,:.:, ,',,":' = I,j,:,' "";:: ');'.::1.E .....~ \-o::q I'''C',C''I-, ,r"~'1 :.- -.......1.::: ';' ',\= ....." ~' 0>4 '1", '....',' .... ...... ( ( l ( ) 1:1 :m~ro'/Ing 11,\:1 Ine present Jclme 01 \:ealman\ remains sialic,' 13 r~\rO;)res3irg IINTE:RIM AOGi\,.\VA7iC1IS CR ACCIDENTS: " Ii () el<\ended atanolng, $111\ng or S\000111g. ( ) , householo 'J~\led \) oulles apo~ndna~\ I': Ih~ patlenl'a regulal emllloymel1l, (l Olher (pltlsse sotlc,IYI_ , ' I"I,gsgNT SU8.JgcTIVe COMPt..~INIS: " , , ! '. . I . .~. ,I, ,.- , . 'i . ~ ,,1 'I' , i ; ! I'! . I" , Ii i '\ . ,! ' !. J.. PROGNOSIS; , ,,.I '~ 'II'" , TREATMENT PLAN: Thle .PE\llel\l 'Ia 10 be seeh Week(e). E\l\d will 1111311 \).3 re-evaluated aller _ \lmo(al a woek for Ihe next ~ . days lot 1)ls/her exlslll1\l heal\ll slall/e. The pallel11 Is/Is not disabled froln Work !II Ihla \lrne beoal/se of Ihla Il1luty, , , '\,'< \('.: 1'" F'" " , .' " il , " i1 " P~A~ONA~ INJURY QI,IJ:~'tIONNAIAr.; N~mfl 6(1l,L/{';!''S M't>t*:ldL4;f~:.. PO\fI 0Ilnlllly--,,-~-?4,~2... PI\ol1o.?,t?':jt!1j' -~$31' Ad~rQoQ .. '?t?4~-(~a(1 ~;:--:-~~,.~. 0IlY---{~rL"~4~/~~ S\~lo-l:4l!lpaO r'~ ~mployor'Q Noma ~.L\2t~::v.~,~._____.~_ ~m(lloY.nr'o Acjelrono -~~~~/~.4~I'~ (,J'( . . , YO,ur Inu, 00: -~~~~':_-i?~~/ /.J ;~:- polloy L C),/, /" -. AOol11'a ~nmo_..__,..-.__ Prlvorlolhur Vohlolo ~f?",.~Llf:I.k.<;:';~____ 1110, op'_"(:..~_I...e.... . policy 11__ , ~ 'HoVo you rololnncl 01) ollor(iuy? () You f\..XNo. Noma ,,~_____ ..., II 't"'. v\? ()' Woro IIwrool1Y 'NllnonQu~s? () Yon I'(<iNo NSfl1o(al___ __.........y~\ ~~v--_.. NAlURIl OP AQQm~NTI , . ) ~ //, __ ,.' ',' .,' ~ I\O)~~ \(' 1, P~\o of AOOIQonl_,~/'~~nmo 01 Pov._~,)(jIPr,J.-( C-,lj'>~/I\e\ '0~L ~ ~\~, ~, Wuro YOUI" ~prlvnr . I I P~uuonoor ~l Front Soul () PaolI 8001' 'I ~,Nlimpar 01 pooplo In your Vohlolo?_..L.__ ,O\hflr vehlolo? __.. I 4, Whal dlroollon 'Nora you 11ooqod? () Nol\l~ (-1<1 ~oal () Soulh( ) WOSI ----s' Q --:::-:. ,J onlnorno 01 alreol)-I_r-.l-L1~~_=_.A~"r.--__ 5, Who I (IIreollon wsa olhor vehlolo homlod? I, I Norll) 'Nt ~osl (I SOllll1 .~-r:;, ,I. -t")/.. 0 (201' onlnol11o olslrooll_.....Lr!-,;I:/'-:!_ -~-~:_::L-.__..____..,____ 6, Wero yo II Slrllck Irom; ~ohlnCl. 1 lFronl () ~oll aldo (I Rlohl sldo 7. Woro YOll l\flockscl unoonaclolla? 1 ,I Yos I\/NO, II voa, lor 110W 10110? " 8, W~re police nollllo(l? () Yea '1)(~0. .' ' . " .c:-1/} :J;.>c':n Y1 .---::;:. ~~/) /,./. T- .9, In YOllr own wardB,~~oanCIOaCrlb(])Oo(?~r 7::2,L,~LI-~~;L--r rr-E("'--;-LfJ~/. . -.({V-a/!;IL;24L t4-/J4.r- --d.-,)...7t1r &2:!.X:.!.L---.;;;a7(;;:..:1 LZ'l.7'::. -L2 ';1 , ;.J:...~'JI ,I /" /' , . / , . .4 / ,/ /' .1'.,1'" , <, ~-.. "-, -", ....~, '---I ~.._"':"-"--;- ------ )Woal ---.---. " 10, Did YOllllavoany pl1yslcolool11plalnlu O~FOR~ ,T1'1li AoCIDeNT?( ) Yoa ~rN?, II yoa, Ploaso Qoaorlho In dololll " _0-.._______ .--.------------- ,. . --____4______ 11, Ploaao dosorlho IIOW YOll loll: . e, DURING \110 OUOldOI1II....:.:...QJ~J}'J2.._._.____ b, iMMIiDIATELY Ar-T~R 1110 acoldonll ~1?.tf1:'I' /-:L.-, , 0, LATlmTHAT DAY: ::l?i-}:U:J___~ . d, THIi NeXT bAY'I'~!.,&):I_kJ , . 12, Whal ate'your PRr;SENT onrl1plolnla and sYf/1fJlol11a? -4.11.,1.//) j/' \ , ~ ~ " /-;l..l.'~7,.(' /d;-lc/~ ::t}((i"L- , ~ , q, HERD CHIROPRACTIC C~INIC, PICI 270,1 MAIlKH STnm I CAMP 1I1~~, peNNSV~VANI^ 1 ~o 11 17171737:1601 flAX 1~17I731'16018 " llilTIA \., RIEPa AT TO: lido lntlllliJ1l\oll PATIf.iNT:. I%\NOEH Flilli':I\ICO..IiYl.liI\ ~MPI-.QYf.;11: !lOIl!llISA/llf\C - PATg'OF INJURY-1L17!97 i. IllQlcl(3ntof InjWry hi.t my vohlolu,1I IISI:O\ll>o<l at t"udllihc , Cllt" hohlnll dId noc SI:01> lInCH cl10Y ~, P~tle,nt's Compl~ln\s Noc~ IH1IIl.1 IIrm \lIlIn, and low blink \lElIn, ~. 4, X-ray Al1~lysls SummEHY ConsIstllnt'wHhdIagnosis, --'- " " ," 7, Pll;\gnosls 723,3 Oarvicobrochil\l syndroma, 723JUorVicl\lgio, 721,.1 I'AInin ':' ~~"".. 124.2 ",,"'. ,., ,;.., "in. .~ ,:'; >3;:~J;\11~ Altern~te Elummary (Comlnents) It is in my ol1inionl \ln~at\ upon t'111t\sallriru:i.~li,;td;.'I,\liM of th!L!l.ccidant , the immediate onaet of symptoms, my ollElmineCion and, IIr~v;find~'),~~f:;!i!iDi\t\:\t .and my elll~,Ode~100 in similllrcllOes, that this occident Wlla thB,O,l\Ua!l, Of, tl\a}>>tu,~K:\i~:l;~[l,iiYjl~ Plsl;\blllty Pata NOIlO, ,"''','';';'''!.flf,1 . ',; i: ;:'r,. i",~:"'i}.-~ :,::'~~;2}:?';,~i{\::';~;~;!II"mi,; "b ~ I' j~:,:,':,;:l,ff/~~\;\):'Y1~:;:~~}~;~Yil ;,,""\1}.1'1 "".-,,~#;)t')1 , :. '.. j,r,:;,'.\ "::iiri:Hm~f;;i~il!lf: 'j', 6. 6, 8, EXl;\mlnatlon Forms AttE\Qhecl? Yes _",-No' " 'i' 9. Acldltlonal evaluations Attaohed? Yes ~- jjp " 10, Aooldent Report AIlE\ohed? Yes No ,. GeraldM. binoher, D,Ct.23n211-092'. 86'108-44-4403 Poot.or's Signature 3I2/J!~1 bllta " "'1':;." ,~ " II .,IIAQNC)$I~ E1HIHH NAM~ ~~a.<J,tf,'..,I'1-1" -1 ,ttl/PAT, 1;" MA, R I, ~.lQ97. IJ,lM a~QMtI.IA.O.~OOY~ PA'I'IJ;NT'a ~RVIOA~ " 7~(j,~ Oervloporllnlpl aynQrPmo 12~1Q.. Qervlnlll Plao l1yndrnmll ' \Z~3) OeryjoplJraot11ol Synqromo "7~Or.l,,, Oervloal Mvnlolll (-1f.lG,1 ) OorVlOAlo11l . C(~fm'- Ol9ryjllPJ NOlimloln, Nliurllla, RmJlpulnr Nmmllolll ?g3.., Oervlo;:ll Pleqrdors, 13r{lohlal Nourllla or RadlclIlIlIs GerVIOI,I Plexus Compression Oompre~alonof ~plnlll Nerve Ronl Oorvlalll'l'ol1lPollIs OarylOllI MyofllS<IIIIS cerylolll 8ppndylllsls aer:v1plll NllllrPVnsc\llllr Compreaslqn Oervlol1l Spraln/Ellrall1 Oervlplll Ploo SYl1Qrome Oerylcooranl~1 Syndrome DeQel1erllllon qf Cervlollllnler- Veneprlll Ploo , nlll,~ 7g4,~ 7114,70 7~4, 71' 7g4,4 7M,3 -'" -... I' ,]g.",?- '----7112:1 363,0 724,9 77,3,5 728.8 738", 33a.9 1l47,0 .. 7gg,0 '7~:3.2 7~g.4 353,4 046,0 722,10 " 7nO,5 . 724,0 ' 939,0 ng,52 , " THQRAt;lIO 61)Pa,n In Thoraolo $pll1e ,. ~;t-n PlsPlao\'lmenl of Thoracllo in!. Oleo 724.4 Neurllis or AM10UIIIIs TI10raolo 786,6 Oheal Fain 706,0 Pyepnel1 ' 788,1 PalplI!\lIons, I., (3fi3.3 Narve Rool IrrllllllonlPegenerllllol1 722,61 P~enerallon olThoraololnl. 0100 LE~ ANo KNIiE 710,46 Pl1ln In Lower Leg 844.8 Sprl1lnlSlraln of /<nee or ~sg SHOULOIiR I\~o ELeoL '; It 91l0.2 "In/ury to Sholllder . '996, (3 ,Injury to ~Ibow 726,8 SynoVItis, !3qraUls, & Tel1osl1oVftln f.lpow 726,10 SynoVllIs, BurslUs, & Tellosnovllla SI10uldot OTUEf:l 83Q,O TMJ SublUXl\lIon 717,0 Paravsrtebral MYOll1llCllIs 780.7 FI1t19Ufl. 40lMl Allthtl1l1i 8ronol1181 7o$l.a I:detl1R 11411.g MlrJra/nll Headaches ' 780.4 Vert/go (Neuropalhlo) Plulnees 470 ,. InnUenzl\ ;' Plsplpppmenl oflnlmvorlllPrl11 \1100 Ploor<<\lrs 911110 ~Uml1osqprl1l or Sf1prolllso Joint lJnspqollleq Ploor<<erlCopoyx flypannollllllyol Q090YX , Naqrllls pr 1~IlQlqVIlIlB, ~uml)oSllorall1;.umllf1r 80lalloa, 8011\110 NeurUls " ~Ull1baup, (low back paJn) Dlspllloemenl 01 ~umbar Inlerver1sl1ral Pls\l w/o MyelopSU1Y ~\lmbAr PlaxusPI~rder ~umpm 8pralnlStrl11n Prolapse, Prolrlls/on, I~UPlljre or Herniation 01 0100 ' Inflammllllon 011110 Hip Jqll1l Othor 8, \,Inapeolflod Dlsorders/Saok 8Ullluxatlon Oegenorllllol1 01 ~urnl)ar/1.umbosRoral InlorVarleoral dloo WAIS'l'. HANI) AND FINGERS 959,ti 955,4 956.9 364,0 6"2,1 726,'1 Injury 10 Wrist Inlury 10 Hand ,. . 111 UIY 10 Nelve In.Hand or Wrist Carpal Tunnel, Syndrome SPtllln/Slr111n of Hl1nd . SynoVllla, SUrslll~: TenQanovllIs Wrlel & Carpua ANKLE, FOO'l' AND. 'l'QES 969,7 846.0 723,7 355,5 OTHER 766,2 729,82 " 626,'4' 760.61 767.0 . 112,5 996.3 6913,1 737,0 070,0 477.9 712,0 960.1 651,13 Gf.l~,() " Injury 10 Ankle or Pilol Sprsln/Slraln 01 Ankls Oalcaneal Spur Tarsal Tunnel syndrome l3edWe1l1ng Menslnlsl Pain/Cramps .. PM8 . Il1sornnln . GI ComplAints Candida Allergles, Uf1speollled FOOd Allergies OUrvnlure 01 8pll111 VirallnleoUon, Uf1speollled AesplraloJy Allergy Arthrtlla 8pondylOsle Hiatal HllI11la Sinus " .' ~~~;t ~ 1~' L ~ ~It>- \Il ~ ~ ' , j I" ~ '" ... ~ F; j I;';;;; l f. ;;;;;;~ J,~. . .. .1' ~~ ij SA;~ I' ! ~] ~ I' ('~ - \ ')~...~ ,~ ~ ~ p ~~~~'~ ~ ~ ~ 3;.;; ;<r ~~~~~l~J 1~ci\..J{l:..jr>: ~ IJ.o\'..Jr>: "-- . fi.f-~fl;1il , ~' ~- ~\ ~AI ~ \ ~,ii! t \ . ~ ' ~l I Q~ ~ \ ~ j ~ ~. '~ !l' ~ l ~ ~ ,~ ~ . .~ l ~ ~ fl g ~ ~:1 iJ,~'~,L\~"~ '" ",_oli;;!~tJl~irl ~d~.t'b..~ .. ~l4.~ ~ t:: ~ il,fllll" .~~ ~~8~ 1~l~~ .-{) ~ ~~r>: ~l - 1 Ll. ~ ' ~ ~..J g F. ~~ tX i]. ',~, ~ :>ll\f- .~~ ~ ~ ~ ~ ~.s '.~. E: ~ i"-.. . ~ ':Ii" 3:;:1~ ~. ~ (.~ ~j~~ P 8 ~ ~I' . '" "~ ~ Ii ~~,,:~t\!t3:~ l~ ,...)>' tq ~ j ~ ,.oNMlflf'o;OO"':B ~ ~ ' " , 'I " . MAIU 8 1991 ,~ '1 ! .~ , , , II il.1 'i, I ,. .j If"~ ,,', " , ,'\ , ~ ' I '~\4 \t Ii <,,- !AOgNT~gNql.OClICA~ Rr:fQ.B.J' ~ATI~NTI~~~OAT''of X,nAY, ~'/ Corvloal 8pll1~ - I Nuoollvo for rocont fr~clllrn or {Jr03~ olloopaUloloo'; OQ vlslloll7.ml, , ' ( 11-000 I,ll (I snvn,rnlY, dncroolocf (I Mllrjly rJooroolo(1 curvloollordcl1lo aurvu, ( NaOnllYo for dlscl1oul1lu 10llon, 1 ) A ",m,1l1'0111 oorvlo 0,' rnyoapllsm, I, I Mild .I' Morl,orot,o I Pootl'O, r.oollools, ( 'Mllcl (, Modorolll l.oyo , soolloals, , I I Mild () Modorotu ( "')"Norl'oworj cllso IPllolla 11U1IVoon ~~ ( . ,.....".- (,i-l-l:f1crooct1molll of U\l'I1Ullroforol))l\Hr'llotWOt!rl,L':- '-;' C...:. \-1 OQ\ooPr\t1rltlo 01 ~ ,'" II'L ( L_( , '. 1.:-' L, ('." ( ) Otllor ,;J r' Tllorsalg..Splna (",';Yfllooo\IYo for rOoOl1t 1I'001llro or gl'~SO 0110l1PotholoGY aa vIIUoll7.ocl, ( I Kyp/1011u cqrvo oppoors l1onn~': ( I Apporol1\ nwospOS!f1, " () Iv111cl , MOcJorola ( I NOOlltlvo 10l'cllsooGanlu loslon, ( ) POXtl'o' 5<1olloslo," ( ) Mllej ) MocJorolo ( ) l-aYQ, 000110515, ( I Mllcf , Morjoro\o ,,( ) Nul'l'oIVocl disc 5P~006 bOlWoon '" ( I Oatoollllhrllls of --"... (, 10\1101'. ( I 50'101'0, ( I Bavoru ( 'Suvoru Apoxuej 0\ Apoxoej 0(--._ - --,-- ( , SO'luio, " ( I 50'/01'0, Apoxod 0\ ( , SO'IOrQ, Apoxod 01 lutl1bor Spino ,. ~ ) Nogo 11'10 for rOOOl1t Iraoturo or Of'OSS oltoopathology os vl6lio1l7.od, ' (', I Los501 (I Sovoruly QOQroused' () MIII1,ly duorooloq IWtnbor 10rrJotlo Ollrvo, ( ) ApPljron\ lumbar myoaposlT1 (I Mild (I MllQOro\O (I Sovoro, ( ) Poxtro '5<10110605, " , (I Mllcl () Modorolo ( , I Sevoro, ( .) L.oyo, 000110615, " ( ,) Mild. I I Modorato (, Suvore, ( ,).-NjiIToW cjli\O spooo betwoon ""':""'T--,r ~ ') .. ( ,.) Anlaulor laoats oppoor to bo ' , I. ( ) S(lonQYlolIs~hos08, grada (,)1 (. ) 2 , 3 ( I Rlollt IlIuI" rothtoQ ( ) Left IlIul11 rolatod ,,, ,. (~I'Cl\l1or"1'l ift; !>, C. . '( . !:xtrOlnltlu8 '- 0\1101' .----.. II ( I , ......:-~ qvorvlow of X. naY "-"Idlnus -~ A(loxsd at A(lo,xsd lit " " ,. I 1 'I "I I I' II " " i ~ ", H ;1 Ii , " ;1\ '!.\ 'i 'I. ,,. j' "I! ;, H " " ;, :'1' H!' " ii" q 'l,O ('') Co \I} il ,. ~,.~ II) '~I ' "'nf., ql 1.1:1 1!,Jq 1 i'j ~:~ '"'I' I',) ,,', 1 1...) .Of.!. f::'h t't) I,. ~IJ :r~ (~::f " .+- ~) ~"J ...... 1'":1 (", 1';' [':jll"l .J:;' h~; ,,'J ' :'.'J ~.I.1 ,~, \0 "", " " " " H .' ,. ':""' f! ,I; ",Ii " I' j' I, 'I ;I " I! Ii ,. ,; 'i, f-' ri' "f> 0 \... ';' , ~, ..... '" '- , ~ <: I:' " ...., 1,;'1.. ''-4.' ..~ ,. " i!, " i' ,i" " ,I" j; j. H '! i '-" ,. " I" " " "