Authorization PDF Form

INSURANCE INFORMATION

Primary Insurance
Insurance Name	{{ $data->primary_insurance_name }}
Member Name	{{ $data->primary_member_name }}
Policy Number	{{ $data->primary_policy_number }}
Certificate Number	{{ $data->primary_certificate_number }}
Date of Birth	{{ $data->primary_dob }}
Relationship to the patient	{{ $data->primary_relationship }}
Secondary Insurance
Insurance Name	{{ $data->secondary_insurance_name }}
Member Name	{{ $data->secondary_member_name }}
Policy Number	{{ $data->secondary_policy_number }}
Certificate Number	{{ $data->secondary_certificate_number }}
Date of Birth	{{ $data->secondary_dob }}
Relationship to the patient	{{ $data->secondary_relationship }}

All Rights Reserved Allistonphysiotherapy © 2026

The Rivermead Post-Concussion Symptoms Questionnaire*

@if($data->other_difficulties_text) @endif

Symptom	0	1	2	3	4
After a head injury or accident some people experience symptoms which can cause worry or nuisance. We would like to know if you now suffer from any of the symptoms given below. As many of these symptoms occur normally, we would like you to compare yourself now with before the accident. For each one, please click the number closest to your answer.
Headaches	headaches == 0 ? 'checked' : '' }}>	headaches == 1 ? 'checked' : '' }}>	headaches == 2 ? 'checked' : '' }}>	headaches == 3 ? 'checked' : '' }}>	headaches == 4 ? 'checked' : '' }}>
Feelings of Dizziness	feelings_of_dizziness == 0 ? 'checked' : '' }}>	feelings_of_dizziness == 1 ? 'checked' : '' }}>	feelings_of_dizziness == 2 ? 'checked' : '' }}>	feelings_of_dizziness == 3 ? 'checked' : '' }}>	feelings_of_dizziness == 4 ? 'checked' : '' }}>
Nausea and/or Vomiting	nausea_and_or_vomiting == 0 ? 'checked' : '' }}>	nausea_and_or_vomiting == 1 ? 'checked' : '' }}>	nausea_and_or_vomiting == 2 ? 'checked' : '' }}>	nausea_and_or_vomiting == 3 ? 'checked' : '' }}>	nausea_and_or_vomiting == 4 ? 'checked' : '' }}>
Noise Sensitivity easily upset by loud noise	noise_sensitivity == 0 ? 'checked' : '' }}>	noise_sensitivity == 1 ? 'checked' : '' }}>	noise_sensitivity == 2 ? 'checked' : '' }}>	noise_sensitivity == 3 ? 'checked' : '' }}>	noise_sensitivity == 4 ? 'checked' : '' }}>
Sleep Disturbance	sleep_disturbance == 0 ? 'checked' : '' }}>	sleep_disturbance == 1 ? 'checked' : '' }}>	sleep_disturbance == 2 ? 'checked' : '' }}>	sleep_disturbance == 3 ? 'checked' : '' }}>	sleep_disturbance == 4 ? 'checked' : '' }}>
Fatigue, tiring more easily	fatigue == 0 ? 'checked' : '' }}>	fatigue == 1 ? 'checked' : '' }}>	fatigue == 2 ? 'checked' : '' }}>	fatigue == 3 ? 'checked' : '' }}>	fatigue == 4 ? 'checked' : '' }}>
Being Irritable, easily angered	irritability == 0 ? 'checked' : '' }}>	irritability == 1 ? 'checked' : '' }}>	irritability == 2 ? 'checked' : '' }}>	irritability == 3 ? 'checked' : '' }}>	irritability == 4 ? 'checked' : '' }}>
Feeling Depressed or Tearful	feeling_depressed_or_tearful == 0 ? 'checked' : '' }}>	feeling_depressed_or_tearful == 1 ? 'checked' : '' }}>	feeling_depressed_or_tearful == 2 ? 'checked' : '' }}>	feeling_depressed_or_tearful == 3 ? 'checked' : '' }}>	feeling_depressed_or_tearful == 4 ? 'checked' : '' }}>
Feeling Frustrated or Impatient	feeling_frustrated == 0 ? 'checked' : '' }}>	feeling_frustrated == 1 ? 'checked' : '' }}>	feeling_frustrated == 2 ? 'checked' : '' }}>	feeling_frustrated == 3 ? 'checked' : '' }}>	feeling_frustrated == 4 ? 'checked' : '' }}>
Forgetfulness, poor memory	forgetfulness == 0 ? 'checked' : '' }}>	forgetfulness == 1 ? 'checked' : '' }}>	forgetfulness == 2 ? 'checked' : '' }}>	forgetfulness == 3 ? 'checked' : '' }}>	forgetfulness == 4 ? 'checked' : '' }}>
Poor Concentration	poor_concentration == 0 ? 'checked' : '' }}>	poor_concentration == 1 ? 'checked' : '' }}>	poor_concentration == 2 ? 'checked' : '' }}>	poor_concentration == 3 ? 'checked' : '' }}>	poor_concentration == 4 ? 'checked' : '' }}>
Taking Longer to Think	taking_longer_to_think == 0 ? 'checked' : '' }}>	taking_longer_to_think == 1 ? 'checked' : '' }}>	taking_longer_to_think == 2 ? 'checked' : '' }}>	taking_longer_to_think == 3 ? 'checked' : '' }}>	taking_longer_to_think == 4 ? 'checked' : '' }}>
Blurred Vision	blurred_vision == 0 ? 'checked' : '' }}>	blurred_vision == 1 ? 'checked' : '' }}>	blurred_vision == 2 ? 'checked' : '' }}>	blurred_vision == 3 ? 'checked' : '' }}>	blurred_vision == 4 ? 'checked' : '' }}>
Light Sensitivity	light_sensitivity == 0 ? 'checked' : '' }}>	light_sensitivity == 1 ? 'checked' : '' }}>	light_sensitivity == 2 ? 'checked' : '' }}>	light_sensitivity == 3 ? 'checked' : '' }}>	light_sensitivity == 4 ? 'checked' : '' }}>
Double Vision Easily upset by bright light	double_vision == 0 ? 'checked' : '' }}>	double_vision == 1 ? 'checked' : '' }}>	double_vision == 2 ? 'checked' : '' }}>	double_vision == 3 ? 'checked' : '' }}>	double_vision == 4 ? 'checked' : '' }}>
Restlessness	restlessness == 0 ? 'checked' : '' }}>	restlessness == 1 ? 'checked' : '' }}>	restlessness == 2 ? 'checked' : '' }}>	restlessness == 3 ? 'checked' : '' }}>	restlessness == 4 ? 'checked' : '' }}>
Are you experiencing any other difficulties?
	other_difficulties_value == 0 ? 'checked' : '' }}>	other_difficulties_value == 1 ? 'checked' : '' }}>	other_difficulties_value == 2 ? 'checked' : '' }}>	other_difficulties_value == 3 ? 'checked' : '' }}>	other_difficulties_value == 4 ? 'checked' : '' }}>

Initial Concussion Patient Interview
Patient Name	{{ $data->patient_name }}
Date of Injury	{{ $data->date_of_injury }}
Date of Assessment	{{ $data->date_of_assessment }}
Referral Signs	@if($data->referral_signs) @php $referral_signs = explode(',',$data->referral_signs); @endphp @foreach($referral_signs as $rs) {{ $rs }} @endforeach @endif
Mechanism of Injury direct_head_contact == 'Direct Head Contact' ? 'checked' : '' }}> Direct Head Contact indirect_whiplash == 'InDirect(whiplash)' ? 'checked' : '' }}> InDirect(whiplash)	{{ $data->mechanism_of_injury }}

Early Symptoms Experienced:	{{ $data->early_symptoms_experienced }}
Relevant Medical Follow Ups, Specialists /Evaluations	{{ $data->specialists_evaluations }}
Imaging, Special Testing, New Medications	{{ $data->imaging_special_testing }}
Occupation at time of Injury	{{ $data->occupation_at_time_of_injury }}
Current Work/Academic Load	@if($data->current_work_academic_load) @php $current_work_academic_load = explode(',',$data->current_work_academic_load); @endphp @foreach($current_work_academic_load as $cwal) {{ $cwal }} @endforeach @endif
Current/Ongoing Symptoms and Functional Limitations	@if($data->current_ongoing_symptoms_and_functional_limitations) @php $current_ongoing_symptoms = explode(',',$data->current_ongoing_symptoms_and_functional_limitations); @endphp @foreach($current_ongoing_symptoms as $cos) {{ $cos }} @endforeach @endif
Notes/other	{{ $data->notes_other }}
History of Concussion or Head/Neck Traum	{{ $data->history_of_concussion }}
Relevant Medical History (Cardio/Neuro/Metabolic/Respiratory)	{{ $data->relevant_medical_history }}

Health History Screening Questions

Headache/Migraine History Pre-Concussion	{{ $data->headache_migraine_history_pre_concussion == 1 ? 'Yes' : 'No' }} {{ $data->headache_migraine_history_pre_concussion_if_yes }}
Pre-Injury Anxiety/Depression?	{{ $data->pre_injury_anxiety_depression == 1 ? 'Yes' : 'No' }} {{ $data->pre_injury_anxiety_depression_if_yes }}
Hx of Learning Disability?	{{ $data->hx_of_learning_disability == 1 ? 'Yes' : 'No' }} {{ $data->hx_of_learning_disability_if_yes }}
Any Known Vestibular Hx?	{{ $data->any_known_vestibular_hx == 1 ? 'Yes' : 'No' }} {{ $data->any_known_vestibular_hx_if_yes }}
Hx Motion Sickness?	{{ $data->hx_motion_sickness == 1 ? 'Yes' : 'No' }} {{ $data->hx_motion_sickness_if_yes }}
Additional Notes	{{ $data->additional_notes }}

All Rights Reserved Allistonphysiotherapy © 2026

Clinical Evaluation P1

CRANIAL NERVE SCREEN	Clear	Abn.
CN I (olfactory)	cn_i_olfactory == 1 ? 'checked' : '' }}>	cn_i_olfactory == 0 ? 'checked' : '' }}>
CN II (visual fields,pupiIlary reflex)	cn_ii_visual_fields_pupillary_reflex == 1 ? 'checked' : '' }}>	cn_ii_visual_fields_pupillary_reflex == 0 ? 'checked' : '' }}>
CN III(H Pattern)	cn_iii_h_pattern == 1 ? 'checked' : '' }}>	cn_iii_h_pattern == 0 ? 'checked' : '' }}>
CN IV(SO - lat/inf)	cn_iv_so_lat_inf == 1 ? 'checked' : '' }}>	cn_iv_so_lat_inf == 0 ? 'checked' : '' }}>
CN V(Sensory/mastication mm)	cn_v_sensory_mastication_mm == 1 ? 'checked' : '' }}>	cn_v_sensory_mastication_mm == 0 ? 'checked' : '' }}>
CN VI(LR-lat)	cn_vi_lr_lat == 1 ? 'checked' : '' }}>	cn_vi_lr_lat == 0 ? 'checked' : '' }}>
CN VII(facial expression mm)	cn_vii_facial_expression_mm == 1 ? 'checked' : '' }}>	cn_vii_facial_expression_mm == 0 ? 'checked' : '' }}>
CNVIII (nystag, whisper)	cn_viii_nystag_whisper == 1 ? 'checked' : '' }}>	cn_viii_nystag_whisper == 0 ? 'checked' : '' }}>
CN IX(taste/posteriortongue)	cn_ix_taste_posterior_tongue == 1 ? 'checked' : '' }}>	cn_ix_taste_posterior_tongue == 0 ? 'checked' : '' }}>
CN X(uvula, swallow, vocal cords)	cn_x_uvula_swallow_vocal_cords == 1 ? 'checked' : '' }}>	cn_x_uvula_swallow_vocal_cords == 0 ? 'checked' : '' }}>
CN IX(Trap,SCM)	cn_xi_trap_scm == 1 ? 'checked' : '' }}>	cn_xi_trap_scm == 0 ? 'checked' : '' }}>
CN IX(tongue mm, articulation)	cn_xii_tongue_mm_articulation == 1 ? 'checked' : '' }}>	cn_xii_tongue_mm_articulation == 0 ? 'checked' : '' }}>

GROSS NEUROVASCULAR
Cerebellar Signs?	{{ $data->cerebellar_signs == 1 ? 'Yes' : 'No' }}
UMN Signs?	{{ $data->umn_signs == 1 ? 'Yes' : 'No' }}
Sensory Changes?	{{ $data->sensory_changes == 1 ? 'Yes' : 'No' }}
Myotome Weakness?	{{ $data->myotome_weakness == 1 ? 'Yes' : 'No' }}
DTRs	{{ $data->dtrs }}
Vast	{{ $data->vast == 1 ? 'Neg' : 'Pos' }}
5D's, 3N's(list)	{{ $data->{'5ds_3ns_list'} }}

All Rights Reserved Allistonphysiotherapy © 2026

Vestibular & Oculomotor Screen

Clinical Evaluation P2 - Special Testing (If Indicated)

All Rights Reserved Allistonphysiotherapy © 2026