HomeMy WebLinkAbout99-01989
tort feasor , Peggy Sieg, failed to yield to the red light she was
facing and violently collided with the Gipe vehicle.
7. As 11 result of the accident, a claim was brought against
the tort feasor, Peggy Sieg.
8. A copy of all of Katie Gipe's accident-related medical
records are attached hereto as Exhibit A.
9. The tort feasor has agreed, through her insurance carrier,
and subject to the approval of Your Honorable Court, to compromise
the claim of Katie Gipe for the sum of $4,000.
10. Your petitioner and her counsel believe that it is in the
best interest of Katie Gipe that the proposed settlement be
accepted and approved.
11. Your Petitioner has obtained the law firm of Angino &
Rovner, P. C. to prosecute this action and has entered into a
contingency fee agreement with said attorneys whereby said
attorneys are to receive for their professional services thirty
(30%) percent of any amount recovered prior to filing suit.
However, under the circumstances, Angino & Rovner has agreed to
reduce their standard fee and accept only twenty-five (25%) percent
($994.94) as a fee for professional services in this case.
12. In addition, the law firm of Angino & Rovner has expended
sums in the amount of $55.06 in order to bring this claim to
settlement. petitioner has agreed, subject to approval of Your
Honorable Court, to pay Angino & Rovner, P.C. said sum.
2
~
DR. MICHAEL K. LEISTER
SOli LOCUST lANE
~iARRISBURC. PENNSYLVANIA 11109.4S22
T.l.pI1on. (II n 6SI.l000
Chl,opt.ClOt
December 2, 1995
James DeCinti
Ang ino & Rovner
4503 North Front Street
Harrisburg, PA 17110-1708
RE. Patient.
Date of Accident.
Treatment Dates.
Katie J. Gipe
07/05/97
07/23/97 to present
Dear Attorney DeCinti:
The above captioned patient was re-examined in this office
on October 14, 1998 for injuries sustained in an automobile
accident. which occurred on July 5. 1997.
CHIEF SYMPTOMS
1, Neck pain
2, Neck cracks
3. Headaches
PAST HISTORY
Non-contributory.
EXAMINATION
Orthopedic. neurological and chiropractic tests were
performed on this patient, Palpable cervical muscle
spasms, palpable edema in the cervical region and
1055 of strength of both legs was present.
X-RAY EXAMINATION
An x-ray examination of the spine was made on October 14,
1998 which exhibited abnormal deviations.
Automo..,lIe Accident aUE:~tionnaire
Please answer all quesllons complelely
0,., PIII,nt Tnl' Informallon IS conSidered confidentIal W. nl'd It1l1 '010"'1'1100 tlecauso we (Bruneug" 10 .....lnllO know, and you' .n......" will
netp uS dtlermln. ., cruraprac!,c can hl'llp you It we do OOI'I"c."I,/ bel.,ve y('\uf condlllon will respond Illl",ClOrlly,...... will nOllcelPl yout CU.
In ora't fat us 10 unCletSland 'lout condlllon properly. please b. IS neallna .ccu,ale as possible while COmplehng tnis lorm Tn.nll YOv
~'e /l~ ". Mil;'" Cola 01 9. N'. DonHom.
Name I <.:>; Sox r Slalu. Birth _ t...'t:.. ~ Phone
Add'... 5 ~ .:>:1. P()&ci~tJ'7 ,'")IJ..mf>l(r' dn LR SIO'. fJt1
Occup.1I0n ",-~.hJ..~~ ,'\.~ Who ,elerred you 10 OUt olllce1 'N\~h"
t1fldlCll' II ,n,ld, 'fudent. housewIfe. unemproyed. ,etlled)
;~~'0;J.q1.lnfI~9(p4j ~~~~:ss
Spous&"! Spouse's
Fltsl Name Soc, Sec. "
12'$..J 9.:)~'"
Zop /'7,19'3
Company
Name
Spouse's
Employe,
locallon
location
Please explain in detail how youtaccident happened
h~~ 'n;\- 'n~~<.\~.
~~I\O\" ," IIe..,,",'UL
~'\CL..\-
Insurance Co. (:I.\\~~
Driver 01 other vehicle (il any)
Insurance
Name ~"'''',L ('<')\9-'-- Company
Driver 01 vehicte in which you were injured (il applicable)
Insurance
Company
Policy No.
Claim No. /~.,1'1q7..35t.~
'\\\\~"\....
Policy No.
Name
Name 01 your insurance adjustor
Have you retained an attorney? 0 Yes 0 No
If so. his name and address
You were heading 0 North 0 East 0 South 0 West on
Other vehicle was headed 0 North 0 East If( South 0 West on
Were police notilied? ~Yes 0 No
Were you knocked unconscious? 0 Yes of..No If so. for how long?
You were struck Irom 0 Behind 0 Front ~Left side 0 Righ! ~ide
You were 0 Driver ~assenger S-Front seat 0 Back seat tkUsing seat belts 0 Other protective devices
What were the time and date of present injury? ~: 30 ? ('(0.. 1- S". 9'1
Where did you feel pain immediately after the accident? c.\_, 'z.:zoO'"
Where were you taken after the accident?
What treatment was given? "'<'>
Was any other doctor consulted after your accident? 0 Yes Ii No
If so, what was the doctor's name?
What was the diagnosis?
What treatment was given?
How often did you see the doctor?
How long did you see the doctor?
Have you ever had any complaints in the involved area before? 0 Yes 0 No
II so, what were the complaints?
Before the injury were you capable 01 working on an equal basis with others your age? 0 Yes 0 No
Are your work activities restricted as a result of this accident? 0 Yes 0 No
Since this injury are your symptoms 0 Improving? 0 Gelling worse? 0 Same?
Policy No.
~G...\\<!.\1
1\ "
:::.\.
\<:'
(street,or highway)
(street or highway)
o D.C.. 0 M.D.. 0 0.0.. 0 D.D.S.
, ~~'.~, C~".:I~'ael.': ".UJ'=~ Fou~a'l'o" 1979
_':"0 ,~. u S J.
.o..n i'<, ~~,
CASE HI"TORY
0111
N.m.
Addllll
7..J~' q'l
1/(\ \H. ('..... 'i"
JD"S Wnhr
t~'
~3 0 q J'G,<,
\ CR~
9'N'p..-z
5..: M cD
5 MOW
Phon. (110m.)
:cu.. ~""""<l.t.'hn ""'- ~_
0.1. 01 Blnh
AO' 9-
MllllAIS,.,u.:
T".phdno (Work)
Oceup.llon
Spoo..'. Nun.
Spoou'. Emplll'(lf
R"lllld By
OOClO". N.m.
Chili Complolnl
Employ.,
Spou..'a Oecupl'lon
Spou..'. T".phon. (Wolk)
PIli Ch'rdprlcllc CtTl 0 YII 0 No Wh.n
Rlluhl
9.<,>\~"A ~ \!>'<-<.:,
1. \i.c:n)...n{\~,..s
2, {\PC'~ "''''-~~ ...
3. ~'<.... ~~~^.l...r
InlUranc. Com piny
SoclllSlCurllyl /q'1:" /".r-<;J~W
SpouI,',lnlurlnc, Co.
C''C~VJ\
~\.i..~
T.I.phon.
T elephon.
All your prlllnt Injurlll dU'lo In Inlury? 0 No 0 YII 0 On Ih'lob
Hm you mid. I llport of your Iccid.nt? 0 No &$lLY1I 0 To emplll'(ir
Hulhllceld.nl blln report.d? 0 No axil 0 Work,,'. Comp,
All you now or hm you .v.r boon dlllbl.d? IS.rvlco or Work)? &:!'-No 0 YII
Hm you lllAln.d In IlIorney? 0 No 0 YII Nam. & Addll..
lJlI"-AotoAccld.nt
G(Auto C.rrler
Cl"\InnoCorrler
Wh.n
o Personlllnjury
CJ Olher
o Olher
o Olher
PLEASE GIVE MOST CURRENT DAlE
Spln.1 Eum
Disc,Ex.m
X.ray Ex.m
L.b Exlm
l.1I Phydcll
fEMALE ONLY
Pap .mlJl
Bre.1I1 eum
IEVERIIY OF PAIN
Ust region 01 plln and chel. &lvllily
numb.r. II . Seut, 10. grula.sl)
u. Neck
I I , (9' I 1 I , 10
/ \
un ~,
,I lIIaHr WJ\K PAIN AREA AlOHr
... Burning
.000 SUbbing
... ShalP
III Consl.1111
I II 45. I "10
2.
1 I , 4" 1 "10
I) l J
:
DDClDRS USE ONLY
I' "
3,
12:1 4 S' 1 "10
~.
5.
12:1 4' I '" \0
I 2:1 4' ""10
Pla..a milk Itll 01 p.ln on tho dllwlno u,'nO th. codall.led .bove,
o Smoking
a D,lnklng
o CoHII
HABIlS
Pa,kslDoy
Alcohol
Cup~ay
Mo'her
Falh"
Brolh", No, of
51.1", No, 01
FAMILY HISIORY
Dlabel.. H..rt Kidney
CI 0 CI
o CI CI
-1-0 a CI
CI a 0
EXERCISE
CI Nona
a Modml.
a Dally
Cilncer
r.J
o
o
CI
HAVE YOU HAD ANY OF THE FOLLOWING DISEASES7
_541 Appendicitis _265.9 Anemia _429,9 Heart D1se318 _716.9 Arthlills
_SolI PneumonLJ _285.9 Meaalea _429.9 Go~er _716.9 Epilepsy
_541 Rheumallc Fev.r _285.9 Mump. _429.9 Inll..nza _716.9 Menl,IDisorde,
_541 Polio _2B5.9 Chicken Pox _429,9 Pleurl,y _716.9 Lumbago
_541 Tuberculosl. _285,9 O~beles ~429.9 Alcoholism _716.9 Emma
541 Whooping Cough _265.9 Cancer _429.9 V.neroal'nlec1ion AIDS
APC,CH.9Il4
UI!
8aek
rrf..
t>?-
O
o
"'iloilO nllllt,: it- ',rlnv'ttut'r'l ~- IPllunllr). '" ',ani 01111 of 1111 10110".1., .Ign.ln' ',lnplolR', b
~IIOU ""III! wll '11". m., .
CEHrn~L SYMPIOMS
___.7840
__7806
_7809
___780.8
__7802
_7804
_7803
_78052
._780.7
_7992
_783
__782
._9953
_786.09
_7292
__847
_722.10
_719
_781
__729.5
_724.79
_724.5
5633
737.3
OAIE
lI..d"h,
11'111
Chili,
Nigh! 5"''''1
lalnling
OlulnOll
COllVullldnl
LOll el SI"p
faligu.
NelVOulnlll
LOll 01 Welghl
Numbn", 0' pain In
arm'~.g''''andl
AIIIIOY (Whal)
Whll/lng
Nemlg'"
.MIRO,INIESTlHAL
_783 Poor Applin.
_536.8 PdOI Dlg"IIon
_994.2 hee..lv. Hungll
_787.3 Belching er 0..
_787 Naul..
_787 Vomiting
_578 Vdmning Blood
_536.8 Pain OVII Sldm"h
_564 Conllipolllon
_558.9 Dl.1r,h""
789 Colon Troubl.
_455.6 IIlmollholdl (PIIII)
_785.1 LIv" Troubl.
_782.4 Jaundice
_575.9 Call BladdlrTroubl.
. bl,nkUnner. A call)" " Mllory '"0 UIIO_IIlI. .
EYElUMlD~tlmROAT
_368.9 Poor VI.lon
_378.9 Crdllld EYII '
_379.91 Pa'n In EYII
..:..-3899 DealnllS
_388.70 Earach.
_388.30 Ear Noises
_388.60 Eo, Dlsch..ges
_478.1 Ila..,IOb,',uctlon
_7e.t.7 Nose Bleedl
_462 SOli Th,o.I,
_7e.t.49 lIo.."no..
_477,9 Hay flVII
_493.9 A.thma
_460 IIIqu.ntColdl
_240.9 Enlarged Thy,oid
_463 Tonllllllll
_686.9 Slnu. T,oubl.
SKIN DR ALLERCIES
_368.9 Skin E,uplionl
_698.9 "ching
_278.8 B,ul.lng Eully
_701.1 Oryno..
Boll.
S.nslllv. Skin
HIv" or Allergy
Eczem3
Medicines
=782
_708.9
_691.9
OPEIlATlOIIS AIID PRDCEOURES
DATE
DATE
Tube. In Ears
Appondeclomy
Female O,g3n.
R'elal Surg.ry
Other
Lista"y accld.nll or lall. and dales: a Car
a School
Lislany brok.n bon.. or disloCo1lionl(Iracluros):
Ever on crulches? c5.No a Vos Why?
11M you ever had any .plnalt.p. or .plnallnjeclion.? 0 Ves ef-No
Were you Iver knocked uncon.dous? 0 Ves b No
lIave you ever had a laps. 01 m.mory? 0 Ves ~ No
Have you ever had x.tayll.ken? 0 No "!TYee Wh.n?
For whal ailmentl were these pielures mad.?
00 you su/ler I,om any condllion olher than Ihal lor which you art now con.ulllng us?
MUSCLE & JOIIITS
Weakness
Twllchlng
SIiH Neck
Backach.
Swoll.n Jolnl'
Tuman
fool Troubl.
Palnlul Tall Bon.
Pain Between
Shoulden
lIernl.
Spinal CUIValur.
CAROID-VASCULAR
_783 Rapid Hea~
427,89 Slow Hoan
_401.9 High Blood PII..U"
458.9 Low Blood PIIIIU"
-786,51 Pain ever H..~
-438 Previous Hea~
- Trouble
_719.07 Swelling Ankles
_759.9 Poo, Circulation
V,ulcose V.lnl
435 Slrokes
o R"reational V..hlclo
o Oth.r
RESrInAIORY
_7852 Ch,onic Cough
_7863 Spining 8100d
_9331 Spilling Phl.gm
_786.5D Chell Pain
_186.09 Olllicully BtUlhln;
GEIIIlO,URINARY
_789.3 Frequenl U,inal,c'
_788.1 Painlul U,lnation
_599.7 Blodd In U,ine
_592 Kidn.y Inl,,'ion
_7883 'Bod Willing
_788.\ In.bihry 10 conlrc!
Urine
_601.9 P,ollal. Tloubl.
_788.2
_625.2
_525,4
_527,2
_525.3
_534.9
_623.5
By Who
Olher
FOR WOMEN ONLY
Palnlul Period.
ExceSStlt Flow
Illlgul.1r Cycle
Hal Flalhes
C'.1mpso,
Backaches
Miscar,iage
V3ginalOischargr
Ptegn.1nl at Ihi, TII
Last Pap
;
Sinus
Hernia
lhy,old
Stomach
Dlher
Vacclnallonl
Tonsllleelomy
G.II Bladder
Back Operation
Other
o SPMs
By whom?
;'ro you presenlly laking any medication. prescription or palenl? 0 No 0 Ves Whal drugs?
w- rd I 'urthlll":lf'f IlI'dcnhrdUvlh D~or'1 Oll'nwllpllpllt 1"'1 mUU'YUpI)rtllrd rOllnllo 1IIlllIT'C!'IIt
j. .-:..~I"II/'Id '9wlfwt "-~II'rd lCI:~ttll nlLflrn pole," 1I1II1I1nt'Qlm,!1 betwt'I\IIl~O'Ia~ .I~h=;"to "'I'~11 ,"'talpl. HClWt"",1 cl~.tyt.rl6lrIW'd 1n<l19r~1 Ihlllll wNlUlllnOc'td mf II' C""QC~ I)
rgt,",1C"_0l'I\ lhllllunm CJ3"""II'f.td ll'wl.", IlnOI,lrf .lJh:lNIId 10 tot pllddtlCl~ 1M, _....~ 'Indllalnr.l.llNl..IOI ptol....lcNl..-.4c:M "rd.red IN .11 bt lIMIt6llllyChA.t'd "'}'1~r,.
l~ lie ,'d ltwlllmp"lOI'IIty nlpo,..tblllo' JIyr'nll"t r .110 llrdllrhnd Ihlll Il.'I"O''' 01 ."...... rrr(QI ..,
/ ulVlCm ftr:ll "'"Jh:llltyrOflhNIPf~l.fflIClblptrlorlld 1lIIIlrdlmo~lrdl~to:l'I'lIIIT\O\II1,"dl~((
''''.1_, I"/'o~t I"" CbclOl' b cumht IMIIM' nycOl"dlbn Ill'll c*/N IPPI'J$III.rt~~h11o* ~I~CH~!I :~~bf"'~'<< '~!lrT1l.H.' plf'ItfIC01 llil df~. nil ~IIII1II.o .g.," 1M twiN II 'npOl'l"bit /Ol.n th II'Cv
IClIII,lltlOllU,nfWI\oolOfltr.rwJl"-iI""1N9'U_wll"m.llllht't'Op.rtyoIIHtOIl.. r:: ; /I'ldoIIcf~l'O~
IIU,lIn 'NDDdot.llrd"'hfId",poflllbl4'OI'IIJ'~IIIrIJ"4~k:lttcf"g/'OMdCl:l'dt 1'01 II".,
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PATIENT a"-:STIONNAlfl~
My gall II your ChiroprlctiC Doctor Is 10 help you with your health problem, Ills ImportlntlhllyOU a'e IrelleO wiln resow 10= ,OJ:
you feel my SllH and I are fulltlltng oUr goals, Pleasl rea, Ihe Queslions below and mark Ihe approp,.ale 00'
yes NO
A 0
0 ~
P- o
0 ~
0 A\
0 -A:
0 ~
Your commenlS are welcome
Were you Ireated wilh respecl and kindness on lha lelephone (or in the oHice) when you scneauleo )0,.
initial appoinlment?
Did you havl any problem IiIling oul our oHlcl forms?
Did you understand Ihe resulls 01 your x.rays and ex Imina lions?
Did you have any Queslions aboul your recommended schedule Ihal were nOI answerea?
Is Ihere any reason you cannol follow the recommended schedule?
Is there anythIng aboul your problem lhallhis oHice should know?
00 you feellhe need 10 discuss anything with lhe Doc lot?
I woulO welcome Ine opportunity to discuss Inis Queslionnaire witn you, Tnank you lor your time and inpul
YOURS IN HEALTH, . /' ./ 1
~vt!~dd,O{',
ho..t~ ~
PATIENT SIGNATURE
^?C,PO.90I2
e...
#It!' /?~/rl
PAli,m "AM, __&JLtz.{~iXAMI~~~:~:.~E~~:'_'_m OIEI
''ArIF.NT tluUOl!n --_, ._. .,~......._...._..____ WRlnE,.. AEPORTc:}Q'/~ECOt,l ~)c'AAYS '.!a!:...I1EHAO ex
INTIALX-RA'/'OAIl____ _._. U.C;BE~,S'='P'O)'TSC-O-L-
"""A< CAOE --....,--_. . ._..,___..__...S""OAOO PnOC~JAE. s,.._fR.7/.iyj. ... .~r I.Lil.-d+_. .......
RESUMEOCARE _'" _ '''_ --IECHNIOUES -&..!lld~ 1'18/>)(, I. /vtr>, LLLP:l.. ___
ABNOnMAl.IflEs...___..... ..~ '__"_.__'_'0'. .__ _ M._._....____. _....__._ _
W- YA. OAfE tlExT
VISIT
--
X,RAY CATE I /1 It.
f:}.!f, ' //1
?;
C
EXAMINATlCN RECCRC
o
L
11345.' I I ] 4 5 1'19101112 I 234
,
ftl
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r X
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EXAM
,'-----t--
l'a NEXI
../.'2- YR, 0..1, TE VISIT
X:RAY, CATE ~
fJiil..J._ , II)!,
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i. ~.EI::- . bi.~
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EXAM
I 2 3 4 5 IS 1 I " J . 5 IS 7 8 9 10 11 11 I " :) 4 5 S R
H-
~
e
101
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