Chiropractic Client Intake Form

Auto Accident Patient Questionnaire

First Name:

Last Name:

Date of Birth:

Social Security #:

Marital Status:

Married Single Divorced Widowed

Email Address:

Address (Home):

City:

State

Zip Code:

Phone (Mobile):

Cell Carrier:

Spouse's Name

Children:

Employer Name:

Auto Accident

Describe your complaints/concerns:

Appproximate date problem began:

Date of accident:

Time (please include am/pm):

Place:

Were seatbelts worn?

Air bag release?

Were you struck from:

Behind Front Left side Right side

Were you:

Driver Passenger Pedestrian

Were you cut or bruised? If so, where?

Did you know the accident was going to happen?

What areas of your body hurt AFTER the accident?

What areas of your body are hurting NOW?

Have you seen another doctor/hospital for your auto accident injuries/symptoms?

If yes, when/where?

Describe type of treatment given:

Have you lost any days of work? If so, which dates?

Have you had previous chiropractic treatment? If so, when and what Dr.?

Name of Family Doctor

All current prescription medication & condition taken for:

All over the counter medication for this condition:

List all operations/surgeries and date performed:

Breast implants?

Pacemaker?

Fractures/broken bones?

Do you suffer from any other disabling conditions or physical impairments not due to this illness or accident? If so, explain:

Family history (if applicable):

Heart Disease Cancer Arthritis Diabetes

Are you pregnant?

Review of Systems

Do you presently have any problems relating to the following systems? Check box if yes:

Psychologic

Are you generally satisfied with your life?

Do you feel severely depressed?

Have you considered suicide?

Other

If Other selected, please describe:

Insurance Information

Do You Have Insurance?

Yes No (Skip to Complaint Summary Section)

Policy Holder

Insurance Company Name:

Company responsible for injuries:

Attorney name:

Are you covered by Medicare?

Do you have group or personal health insurance?

Please have receptionist make a copy of your insurance card upon first visit.

Your information will be encrypted.