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New Patient Form – Personal Injury
Home
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New Patient Form – Personal Injury
New Patient Form – Personal Injury
Kurt Abel
2021-09-23T19:40:59+00:00
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Patient Data
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Day
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Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions.
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email
text
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Afghanistan
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Cell Phone
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Referred By
Age
(Required)
Date of Birth
(Required)
Month
Day
Year
Number of Children
(Required)
Occupation
(Required)
Employer
Marital Status
(Required)
Married
Divorced
Separated
Widowed
Single
Spouse's Name
(Required)
Spouse's Occupation
(Required)
Emergency Contact
(Required)
Emergency Contact Phone
(Required)
Payment Information
Auto Insurance
(Required)
Yes
No
Attorney/Lien
(Required)
Yes
No
Out of Pocket
(Required)
Yes
No
Please note: we do not bill medical insurance for any injuries sustained from an auto accident
If going through auto insurance, please provide: Auto Insurance Carrier
Is this your policy or the policy of the other party:
Claim Number:
Adjuster’s Phone Number:
Please provide detailed information regarding the accident (If not applicable, please enter n/a):
Date and time of accident
(Required)
Location of Accident/Incident:
(Required)
Type of Accident:
(Required)
Motor vehicle
Other
If other, please explain
(Required)
Please describe (in detail) how the accident occurred:
Please check your location in the vehicle
(Required)
driver
front passenger
back driver-side passenger
back middle passenger
back right passenger
n/a
How many passengers were in the vehicle you were in? (enter n/a if not applicable)
(Required)
Were you wearing a seatbelt?
(Required)
yes
no
n/a
Were you a pedestrian struck by a car?
(Required)
yes
no
Describe the vehicle you were physically in when the accident occurred including year, make, and model. (enter n/a if not applicable)
(Required)
Please describe the other vehicle involved in this accident.
(Required)
Did any part of your body strike any part of the vehicle?
(Required)
yes
no
Where did you first notice pain after the accident?
(Required)
When did you first notice pain after the accident?
(Required)
Estimate how fast your vehicle was moving at the time of the crash, in mph (enter n/a if not applicable)
(Required)
Estimate how fast the other vehicle was moving at the time of the crash, in mph (enter n/a if not applicable)
(Required)
At the time of the impact, your vehicle was
(Required)
slowing down
gaining speed
moving at a steady speed
n/a
At the time of the impact, the other vehicle was
(Required)
slowing down
gaining speed
moving at a steady speed
n/a
Non Motor Vehicle Accidents
What were you doing at the time of the incident?
(Required)
Were there any other persons involved in this incident?
(Required)
yes
no
Where did you first notice pain after the accident?
(Required)
When did you first notice pain after the accident?
(Required)
Medical Care
Is this the first healthcare professional you have seen for your accident injuries?
(Required)
yes
no
Were you treated by paramedics?
(Required)
yes
no
Did you go to the emergency room?
(Required)
yes
no
Did you go to a doctor’s office?
(Required)
yes
no
Name and address of facility:
(Required)
Please describe the treatment you received.
(Required)
Were x-rays or any diagnostic exams taken (including blood tests)?
(Required)
yes
no
Please list the type(s) of tests and location.
(Required)
Did you receive medications?
(Required)
yes
no
Please name the physician who prescribed the medication(s) and the names.
(Required)
Are the medications helpful for your symptoms?
(Required)
yes
no
If you did not seek medical treatment on the day of your accident, when did you seek treatment?
If you did not seek a doctor after the accident, please indicate why.
Did you treat yourself with any of the following (please check all that apply):
Ice
Heat
Massage
Over the counter medications
Other
Please describe other treatments:
(Required)
Are you feeling:
(Required)
better
worse
Have you been able to work since the injury?
(Required)
yes
no
If you have been unable to work, how many days of work have you missed?
(Required)
Please acknowledge that by signing below and returning to the doctor’s office, you hereby confirm that all the information reported above is factual.
Date
Month
Day
Year
Previous Care
When was the last time that you received chiropractic, massage, or acupuncture?
(Required)
Do you self adjust?
(Required)
yes
no
How often do you self adjust?
(Required)
at least once a day
multiple times a day
as soon as I feel stiff
Please list locations that you self adjust:
(Required)
Medical History
Have you been treated for any condition in the last year?
(Required)
yes
no
Please describe
(Required)
Date of last physical exam
(Required)
Month
Day
Year
Is there a chance you are pregnant?
(Required)
yes
no
Have you had X-rays taken?
(Required)
yes
no
Where were the X-rays taken?
(Required)
What medications are you taking and for what conditions (Please list dosage and amounts, etc). If none, please type none.
(Required)
What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency). If none, please type none.
(Required)
Have you ever:
Broken bones?
(Required)
yes
no
Breifly explain hospitalizations
(Required)
Been hospitalized?
(Required)
yes
no
Breifly explain any broken bones
(Required)
Been in an auto accident?
(Required)
yes
no
Breifly explain any auto accidents
(Required)
Had sprains/strains?
(Required)
yes
no
Breifly explain any sprains/strains
(Required)
Been struck unconscious?
(Required)
yes
no
Breifly explain being struck unconscious
(Required)
Had surgery?
(Required)
yes
no
Breifly explain any surgeries
(Required)
Family History
Please list any family members and any past or current health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.) If none, please enter none.
(Required)
Your Current Condition
Do you experience pain every day?
(Required)
yes
no
Do your symptoms interfere with daily life?
(Required)
yes
no
Does pain wake you up at night?
(Required)
yes
no
Are your symptoms worse during certain times of the day?
(Required)
yes
no
Do changes in weather affect your symptoms?
(Required)
yes
no
Do you wear orthotics?
(Required)
yes
no
Do you take vitamin supplements?
(Required)
yes
no
Please list any activities that aggravate your symptoms:
Please check if you currently have or have a history of:
Alcoholism
Currently Have
Have a History of
Allergies
Currently Have
Have a History of
Anemia
Currently Have
Have a History of
Arteriosclerosis
Currently Have
Have a History of
Arthritis
Currently Have
Have a History of
Asthma
Currently Have
Have a History of
Back Pain
Currently Have
Have a History of
Breast lump
Currently Have
Have a History of
Bronchitis
Currently Have
Have a History of
Bruise Easily
Currently Have
Have a History of
Cancer
Currently Have
Have a History of
What type of cancer?
(Required)
Chest Pain/Conditions
Currently Have
Have a History of
Cold extremities
Currently Have
Have a History of
Constipation
Currently Have
Have a History of
Cramps
Currently Have
Have a History of
Depression
Currently Have
Have a History of
Diabetes
Currently Have
Have a History of
Digestion Problems
Currently Have
Have a History of
Dizziness
Currently Have
Have a History of
Ears Ring
Currently Have
Have a History of
Excessive Menstruation
Currently Have
Have a History of
Eye Pain/Difficulties
Currently Have
Have a History of
Fatigue
Currently Have
Have a History of
Frequent Urination
Currently Have
Have a History of
Headache
Currently Have
Have a History of
Hemorrhoids
Currently Have
Have a History of
High Blood Pressure
Currently Have
Have a History of
Hot Flashes
Currently Have
Have a History of
Insomnia
Currently Have
Have a History of
Irregular Heart Beat
Currently Have
Have a History of
Irregular Cycle
Currently Have
Have a History of
Kidney Infection
Currently Have
Have a History of
Kidney Stones
Currently Have
Have a History of
Loss of Balance
Currently Have
Have a History of
Loss of Memory
Currently Have
Have a History of
Loss of Smell
Currently Have
Have a History of
Loss of Taste
Currently Have
Have a History of
Neck Pain or Stiffness
Currently Have
Have a History of
Nervousness
Currently Have
Have a History of
Nosebleeds
Currently Have
Have a History of
Pacemaker
Currently Have
Have a History of
Phobias
Currently Have
Have a History of
Please list any phobias
(Required)
Polio
Currently Have
Have a History of
Poor Posture
Currently Have
Have a History of
Prostate Trouble
Currently Have
Have a History of
Sciatica
Currently Have
Have a History of
Shortness of breath
Currently Have
Have a History of
Sinus Infection
Currently Have
Have a History of
Sleep problems/insomnia
Currently Have
Have a History of
Spinal Curvatures
Currently Have
Have a History of
Stroke
Currently Have
Have a History of
Swelling of ankles
Currently Have
Have a History of
Swollen Joints
Currently Have
Have a History of
Thyroid Condition
Currently Have
Have a History of
Other:
Currently Have
Have a History of
Please list any others
(Required)
Consent
(Required)
Please check this box confirm that you have read and filled out all the information above. Please note: If you cannot make your appointment, please notify us within 24 BUSINESS hours. There is a $20.00 fee for any cancellation or rescheduled appointments less than 24 BUSINESS hours before your scheduled time or missed appointments. Please note that auto insurance and personal injury settlements do not cover cancellation fees.
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(Required)
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Date
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