New Patient Form - Personal Injury - Lander Chiropractic

Step 1 of 12

Patient Data

Name(Required)

First Last

Date(Required)

Month

Day

Year

Email(Required)

Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions.

Cell Phone Carrier

How would you like to receive appointment reminders?(Required)

text

Mailing Address

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Home Phone

Referred By

Age(Required)

Date of Birth(Required)

Month

Day

Year

Number of Children(Required)

Occupation(Required)

Employer

Marital Status(Required)

Spouse's Name(Required)

Spouse's Occupation(Required)

Emergency Contact(Required)

Emergency Contact Phone(Required)

Payment Information

Auto Insurance(Required)

Yes

Attorney/Lien(Required)

Yes

Out of Pocket(Required)

Yes

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

n/a

Were you a pedestrian struck by a car?(Required)

yes

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

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

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

Were you treated by paramedics?(Required)

yes

Did you go to the emergency room?(Required)

yes

Did you go to a doctor’s office?(Required)

yes

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

Please list the type(s) of tests and location.(Required)

Did you receive medications?(Required)

yes

Please name the physician who prescribed the medication(s) and the names.(Required)

Are the medications helpful for your symptoms?(Required)

yes

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

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

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

Please describe(Required)

Date of last physical exam(Required)

Month

Day

Year

Is there a chance you are pregnant?(Required)

yes

Have you had X-rays taken?(Required)

yes

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

Breifly explain hospitalizations(Required)

Been hospitalized?(Required)

yes

Breifly explain any broken bones(Required)

Been in an auto accident?(Required)

yes

Breifly explain any auto accidents(Required)

Had sprains/strains?(Required)

yes

Breifly explain any sprains/strains(Required)

Been struck unconscious?(Required)

yes

Breifly explain being struck unconscious(Required)

Had surgery?(Required)

yes

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

Do your symptoms interfere with daily life?(Required)

yes

Does pain wake you up at night?(Required)

yes

Are your symptoms worse during certain times of the day?(Required)

yes

Do changes in weather affect your symptoms?(Required)

yes

Do you wear orthotics?(Required)

yes

Do you take vitamin supplements?(Required)

yes

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.

Signature(Required)

Please use your mouse or finger to sign in this box.

Date(Required)

Month

Day

Year

Call to Make an Appointment (714) 626-0074

New Patient Form – Personal Injury

Patient Data

Mailing Address

Payment Information

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

Non Motor Vehicle Accidents

Medical Care

Previous Care

Medical History

Have you ever:

Family History

Your Current Condition

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

Lander Chiropractic