Trusted Medical Professionals

While medication cannot replace the value of therapy and rehabilitation following an accident, it can facilitate the healing process and provide much needed relief to the patient.  Muscle and joint pain, stiffness and soreness are just some of the common side effects patients experience after injury, as well as headaches, dizziness, and difficulty sleeping.  Medical doctors and nurse practitioners evaluate our patients and prescribe a course of medication and treatment designed to facilitate efficient, quality recovery. While Trusted Medical only provides the medical component of patient care, we work with a network of therapists, chiropractors, diagnostic facilities and other highly trained specialists to ensure our patients are cared for through every phase of the healing process.

Accident & Injury Case Management

Trusted Medical Providers is a medical group that specializes in treatment and case management for injured patients.  Our primary focus is on making sure each patient receives the services needed to fully recover from their injuries. Our medical providers prescribe appropriate medications to assist the body in healing, order diagnostic tests needed to determine the full extent of patient injuries, and refer to the best healthcare providers in the Metroplex for therapy, rehabilitation, neurology, pain management, psychological, dental, and orthopedic services as needed.

Locations

We welcome patients throughout the Greater Dallas-Fort Worth area; if you have been involved in an accident, we’re here to help

Patient Intake Forms

    New Patient Information (*=Required Field)
















    MaleFemale

    SingleMarriedSeparatedDivorcedWidowed


















    SpouseFamilyFriendOther








    SpouseFamilyFriendOther


    Insurance Information


    YesNo

    If yes please bring insurance card to the office on your first visit.

    Auto Insurance Information


    Auto InsurancePersonal Injury Protection (PIP)Uninsured MotoristMed Pay















    Third Party Liability (if applicable)









     If you do not have the information of the person at fault, please bring the third party liability information with you on your next visit. Thank you! 



    Review of Symptoms


    N/AFaintingLow LibidoPoor AppetiteFatigueSudden Weight GainSudden Weight LossWeakness

    N/AAsthmaApneaEmphysemaHay FeverShortness of BreathPneumonia

    N/AHigh Blood PressureLow Blood PressureHigh CholesterolPoor CirculationAnginaExcessive Bleeding

    N/AAnorexia/BulimiaUlcerFood SensitivitiesHeartburnConstipationDiarrhea

    N/AKidney StonesInfertilityBedwettingProstate IssuesErectile DysfunctionPMS Symptoms

    N/ASkin CancerPsoriasisEczemaAcneHair LossRash

    N/ABlurred VisionRinging in EarsHearing LossChronic Ear InfectionLoss of SmellLoss of Taste

    N/AThyroid IssuesImmune DisordersHypoglycemiaFrequent InfectionSwollen GlandsLow Energy


    History

    Mother's Family History




    GoodFairPoorN/A

    NaturalIllnessOtherN/A-Still Living

    CancerStrokeHeart DiseaseDiabetesAuto-ImmuneN/A


    Father's Family History





    GoodFairPoorN/A


    NaturalIllnessOtherN/A-Still Living

    CancerStrokeHeart DiseaseDiabetesAuto-ImmuneN/A


    Social History
















    Past Medical History


    N/AAIDSAlcoholismAllergiesArteriosclerosisCancerChicken PoxDiabetesEpilepsyGlaucomaGoiterGoutHeart diseaseHepatitisHIV PositiveMalariaMeaslesMultiple SclerosisMumpsScarlet feverSexually transmitted diseasePolioRheumatic feverStrokeTuberculosisTyphoid feverUlcer




    Any surgeries PRIOR to injury?


    N/AAppendix removalBypass surgeryCancer relatedCosmetic surgeryEye surgeryHysterectomyPacemakerTonsillectomySpinal SurgeryJoint Surgery






    Medications & Allergies

    Please list below all prescription, over-the-counter or natural supplements you are taking




    Are you allergic to any medications?


    YesNoNot Sure

    If yes, please list

    Dominant Hand



    RightLeftAmbidextrous (both)


    ACCIDENT INFORMATION


    Select The Type of Accident You Had


    Auto AccidentSlip & Fall/Personal Injury


    "PERSONAL INJURY or SLIP/FALL"


    YesNo

    Describe How and Where the injury occurred:











    FallSlipTripOther

    ForwardBackwardsLeftRightN/A





    YesNo





    YesNoN/A




    YesNo

    YesNoNot Sure


    Upload INJURY Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes

    [mfile upload-file-158 filetypes:jpeg|png|jpg File size limit:5242880 Bytes]

    "MOTOR VEHICLE ACCIDENT (Patient)"


    Yes (Bring Copy)No


    Motor Vehicle Information






    Rear-endedFront-end impactedT-Boned Driver SideT-Boned Passenger SideRolloverSide Impact Driver SideSide Impact Passenger SideOther

    FrontSideRearOther



    DryRainIceFogOther

    MorningNoonAfternoonEveningOvernight





    MECHANISM OF INJURY





    DriverFront PassengerLeft-Rear PassengerMiddle-Rear PassengerRight-Rear PassengerOther


    YesNo

    YesNo

    YesNo

    Straight AheadLeftRightUnsure

    YesNoUnsure


    Upload MOTOR VEHICLE ACCIDENT Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes

    [mfile upload-file-159 filetypes:jpeg|png|jpg File size limit:5242880 Bytes]

    Upload INJURY Pictures | Filetypes:jpeg|png|jpg File size limit:5242880 Bytes

    [mfile upload-file-160 filetypes:jpeg|png|jpg File size limit:5242880 Bytes]

    Post-Injury Questionnaire


    YesNo

    YesNo



    Immediately AfterA few hours afterOne day laterA few days laterCan't Remember

    MRICT ScanX-RaysTests conducted Lying DownTests Conducted Standing



    YesNo

    YesNo




    SINCE THE ACCIDENT


    Prescription medicationOTC medicationHomeopathic remediesSurgeryAcupunctureChiropractic careIceHeatMassagePhysical TherapyRestPain Relief CreamsWearing a support/braceOtherNone




    ACTIVITIES OF DAILY LIVING


    SittingRising out of chairStandingWalkingLying downBending overClimbing stairsDriving a carTurning headHousehold choresLifting objectsReaching upShowering or bathingGetting dressedLove lifeSleepConcentratingExercisingOtherNone




    Work Status


    YesNo




    YesNo

    StudentRetiredDisabledHomemaker


    YesNo




    A doctor took you off workYou took yourself off workYou had no transportation after the accidentYour boss took you off workYou were fired or lost your job as a result of this accidentOther




    YesNoN/A

    YesNoN/A


    YesNoN/A




    Any information that is not provided while filling out this form will need to be reviewed at the clinic on your first visit. By providing this information at this time, your initial appointment intake process will not be so lengthy. Your doctor will need a health history to complete the initial exam.

    Additional forms will need to be signed when you arrive at the clinic on your first visit.
    Please bring a photo ID and any previous care information related to your accident if applicable.
    Thank you!

    Providers

    Click Provider to view their CV

    Dr. Madhav          Iqbal Gill, FNP          Phil Bome, FNP