Part 2: Patient Intake







*Sex:



Marital Status:

           









Employment Status:


















Referred By:

           




Reason For This Visit:









How do you intend to pay:














Have you seen a chiropractor before?

   







Previous car accidents?

   

Serious Illness / Hospitalizations / Surgeries?

   

Please check whether you have the following symptoms now or in the past.



































































































































































Tobacco Use:





Alcohol Use:



Drug Use:





HAVE YOU BEEN IN A WORK RELATED INJURY?











MOTOR VEHICLE ACCIDENT

CLICK TO SKIP IF YOU ARE NOT IN FOR A CAR ACCIDENT







Were you the:







ACCIDENT SITE






Driving Conditions:






IMPACT

Did your car impact another vehicle:


Did your car impact a structure:






Did any part of your body strike anything in the vehicle?



If yes, explain:

Was impact from:



Left
Right


At the time of impact were you:



Looking up
Looking to the right
Looking Down

Were both hands on the steering wheel:




If no, which hand was on the wheel:




Was your foot on the brake:




If yes, which foot was on the brake:




Were you:




VEHICLE



Were you wearing a seatbelt:




If yes, what type:




Was vehicle equipped with airbags:




If yes, did it inflate properly:




Did your seat have a headrest:




If yes, what was the position of the headrest:





OTHER VEHICLE





POLICE

Did the police come to the accident site:




Any Witnesses:




Police report filed:




Was a traffic violation issued:





PATIENT CONDITION

Were you unconscious immediately after the accident:





Please describe how you felt immediately after the accident:


TREATMENT

Did you go to the hospital:




When did you go if so:





How did you get to the hospital:










SYMPTOMS/INJURIES

Have you been able to work since this injury:






Prior to the injury were you able to work on an equal basis with others your age:




Mark any of the following symptoms you've had since your injury:

























Is this condition getting progressively worse:








Type Of Pain:




















Does it interfere with your:






Movements that are painful to perform:







MOTOR VEHICLE ACCIDENT QUESTIONNAIRE

Have you continued to do any of the following activities despite the pain caused by your collision?

WORK

Why have you continued to work?








I have experienced the following changes in my ability to perform at work:























Problems with reduced concentration?





Duration of symptoms:






DOMESTIC DUTIES:

I have experienced pain while performing the following activities inside my home but have done them anyway:









Due to my injuries, I have brought in the following assistance:





My family status would be described as:







The number of my children in the following age category is:





Duration of Symptoms: [choose 1]






Household:

I have experienced problems with the following activities outside my home:













Duration of symptoms:






Studies / Educational Duties:






I have also experienced the following changes in my ability at school as a result of injuries sustained in this collision:























Problems with reduced concentration:





Check any symptoms you have:




























































MOTOR VEHICLE ACCIDENT INSURANCE INFORMATION


















OTHER DRIVER INFORMATION