Skip to content
FacebookTwitterInstagramYouTube

Call to Make an Appointment (714) 626-0074

Lander Chiropractic – Your Brea Chiropractor Logo Lander Chiropractic – Your Brea Chiropractor Logo Lander Chiropractic – Your Brea Chiropractor Logo
  • Home
  • COVID-19 Response
    • PreScreening Form
  • About
    • Meet the Doctors
    • Mission
    • Giving Back
  • Blog
  • Videos
    • Home Exercise Recommendations
    • Story Time With Dr. A
  • What We Do
    • Chiropractic Care
    • Chiropractic Care for Children
    • Sports Injuries
    • Pregnancy Care
    • Acupuncture
  • Contact

New Patient Form – Personal Injury

Home/New Patient Form – Personal Injury
New Patient Form – Personal InjuryKurt Abel2021-09-23T19:40:59+00:00

Step 1 of 12

8%

Patient Data

Name(Required)
Date(Required)
Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions.
How would you like to receive appointment reminders?(Required)

Mailing Address

Address(Required)
Date of Birth(Required)

Payment Information

Auto Insurance(Required)
Attorney/Lien(Required)
Out of Pocket(Required)
Please note: we do not bill medical insurance for any injuries sustained from an auto accident

Please provide detailed information regarding the accident (If not applicable, please enter n/a):

Type of Accident:(Required)
Please check your location in the vehicle(Required)
Were you wearing a seatbelt?(Required)
Were you a pedestrian struck by a car?(Required)
Did any part of your body strike any part of the vehicle?(Required)
At the time of the impact, your vehicle was(Required)
At the time of the impact, the other vehicle was(Required)

Non Motor Vehicle Accidents

Were there any other persons involved in this incident?(Required)

Medical Care

Is this the first healthcare professional you have seen for your accident injuries?(Required)
Were you treated by paramedics?(Required)
Did you go to the emergency room?(Required)
Did you go to a doctor’s office?(Required)
Were x-rays or any diagnostic exams taken (including blood tests)?(Required)
Did you receive medications?(Required)
Are the medications helpful for your symptoms?(Required)
Did you treat yourself with any of the following (please check all that apply):
Are you feeling:(Required)
Have you been able to work since the injury?(Required)
Date

Previous Care

Do you self adjust?(Required)
How often do you self adjust?(Required)

Medical History

Have you been treated for any condition in the last year?(Required)
Date of last physical exam(Required)
Is there a chance you are pregnant?(Required)
Have you had X-rays taken?(Required)

Have you ever:

Broken bones?(Required)
Been hospitalized?(Required)
Been in an auto accident?(Required)
Had sprains/strains?(Required)
Been struck unconscious?(Required)
Had surgery?(Required)

Family History

Your Current Condition

Do you experience pain every day?(Required)
Do your symptoms interfere with daily life?(Required)
Does pain wake you up at night?(Required)
Are your symptoms worse during certain times of the day?(Required)
Do changes in weather affect your symptoms?(Required)
Do you wear orthotics?(Required)
Do you take vitamin supplements?(Required)

Please check if you currently have or have a history of:

Alcoholism
Allergies
Anemia
Arteriosclerosis
Arthritis
Asthma
Back Pain
Breast lump
Bronchitis
Bruise Easily
Cancer
Chest Pain/Conditions
Cold extremities
Constipation
Cramps
Depression
Diabetes
Digestion Problems
Dizziness
Ears Ring
Excessive Menstruation
Eye Pain/Difficulties
Fatigue
Frequent Urination
Headache
Hemorrhoids
High Blood Pressure
Hot Flashes
Insomnia
Irregular Heart Beat
Irregular Cycle
Kidney Infection
Kidney Stones
Loss of Balance
Loss of Memory
Loss of Smell
Loss of Taste
Neck Pain or Stiffness
Nervousness
Nosebleeds
Pacemaker
Phobias
Polio
Poor Posture
Prostate Trouble
Sciatica
Shortness of breath
Sinus Infection
Sleep problems/insomnia
Spinal Curvatures
Stroke
Swelling of ankles
Swollen Joints
Thyroid Condition
Other:
Consent(Required)
Please use your mouse or finger to sign in this box.
Date(Required)

About Us

We want to empower you to take control of your health as it is our desire to assist you and your family in achieving optimum health, wellness, and longevity.

Lander Chiropractic

1203 Imperial Hwy #100
Brea, CA 92821
Phone: (714) 931-0475
Fax: (714) 582-1727

Main Office - Brea

Click to open a larger map

Office Hours

Monday - Saturday by appointment only. No walk-ins.

Our Services

Pages

  • Acupuncture
  • Bloom Attendee Raffle
  • Chiropractic Care
  • Chiropractic Care for Children
  • Chiropractic Care for Sports Injuries
  • Home Exercise Recommendations
  • New Acupuncture Patient Form
  • New Patient Form – Personal Injury
  • New Patient Form – Pregnancy
  • New Patient Health History Form
  • New Pediatric Patient Health History Form
  • Pregnancy Care
  • Safety & Support – Your Health & Concerns Matter To US: COVID-19 Response
  • Story Time With Dr. A

Connect With Us!

We are ICPA Certified

Copyright 2017 Lander Chiropractic | All Rights Reserved | Website by Two Cans Media
FacebookTwitterInstagramYouTube
Subscribe To The
Lander Letter
Get healthy recipes, health hacks, pregnancy and new mom tips, and be the first to know about our events and raffles.
Stay Updated
Give it a try, you can unsubscribe anytime.
close-link
Powered by Convert Plus
Go to Top