goodyearchiropractic.com - Auto Accident Intake

Auto Accident Intake
Name:
Date:

Month Day Year
When did the accident occur?

Month Day Year
Which were you?

Driver Front Passenger Rear Passenger Pedestrian
Your vehicle:

Car Truck SUV
Vehicle that hit you:

Car Truck SUV
Occurred at:

Intersection Parking Lot Freeway Town
What direction were you headed?

Northbound Eastbound Westbound Southbound
At impact, was your vehicle?

Parked Stopped Slowing
When?

Dawn Morning Afternoon Dusk Night
Driving conditions:

Normal Dry Stormy Wet Wind
Where was the impact?

Driver side Passenger side Front Rear
Did you hit another car or object after 1st impact?

No Another Car Object
Body hit the vehicle interior:

Head Face L / R Shoulder Chest L / R Knee
Where were you looking at time of impact?

Fwd Rear Left Right Up Down
Driver: which hands were on the steering wheel?

Both Right Left None
Driver: which foot was on the brake?

Right Left Both Neither
Head restraint position:

Middle High Low No Head Restraint
Air bag deployed:

Steering Wheel Driver Side Passenger Side None
Were you wearing a seat belt?

Yes No Child Restraint
What doors did not open?

Rear Hatch Trunk Front Driver Side Front Passenger Rear Driver Side Rear Passenger Side All doors opened freely
Hospitalized:

Abrazo West Banner Estrella Dignity Urgent Care Other
Treatment:

Medications X-Ray CT Scan Neck Braces Other
Medications:

Ibuprofen Flexeril Oxycodone Percocet Tyleno Advil Aleve Other
Did you see your PCP?

Yes No
When?
Dr.
Home care done:

Over the Counter Meds Ice Heat Rest Avoid Activity Followed instructions of ER Followed instructions of PCP
Occupation:
Missed Days:
Light Duty:

Yes No
How did you feel before your accident?

Pain No Pain
Do you have any serious pre-existing neck or back conditions?

Yes No
Have you been in a previous car accident?

Yes Never
When?
Were you hurt?

Yes No
Received medical care?

Yes No
Released pain free?

Yes No
Daily Habits:

0 = none 1 = a little 2 = moderate 3 = a lot
Smoking:

0 1 2 3
Alcohol:

0 1 2 3
Exercise:

0 1 2 3
Dominant Hand:

Left Right
Please Select Those Where You Are Having Symptoms?

Neck Pain Low Back Pain Headache Left / Right Blurry Vision Left / Right Shoulder Pain Left / Right Hand Pain Left / Right Hip Pain Left / Right Foot Pain Left / Right Rib Pain Left / Right Arm Numb Left / Right Leg Numb Vertigo Left / Right Ear Ringing Left / Right Elbow Pain Left / Right Arm Pain Left / Right Knee Pain Left / Right Leg Pain Chest Pain Mid Back Pain Left / Right Sciatica Short Term Memory Loss Left / Right Jaw Pain Left / Right Wrist Pain Stomach Pain Left / Right Ankle Pain Left / Right Leg Cuts/Bruise Left / Right Arm Cuts/Bruise
Pain Level:

3 4 5 6 7 8 9 10
Type:

Aching Sharp Cramping Radiating Stiff Spasm Burning Tight Tingling
Freq:

Constant Worse at night Frequent Worse in Afternoon Worse in Morning
Which Activities Aggravate Your Condition?

Back Movement Neck Movement Sneezing Bending Reaching Standing Coughing Sex Using Restroom Driving Sitting Walking House Chores Sleeping Yard Work Lifting Other
Please Select Any Recent Change in the Following Functions?

Absence of Smell Fainting Mouth Bleeding Anxiety Fatigue Mouth Sores Appetite Change Forgetfulness Nail Change Blue Arms Frequent Urination Night Sweats Blue Legs Hair Change Nose Bleeds Change in Taste Hearing Trouble Nose Pain Cold Intolerance Heart Murmurs Painful Urination Concentration Heat Intolerance Palpitations Convulsion Impotence Rash / Redness Cough Wheezing Inability to Urinate Swollen Arms Depression Itching Swollen Legs Difficulty Breathing Memory Loss Tremors Digestive Changes Mood Swing Weight Changes Ear Pain
For Females:
Are you pregnant?

Not Sure Yes No
Breast Lump Discharge of Breast Vaginal Bleeding Breast Pain Irregular Menstruation Vaginal Pain Breast Red/Itching
Family Illness:

Father Mother Sibling
Illness?
Please Select Any of the Following Disorders that Apply to You:

Allergies Hay Fever Rheumatic Fever Arthritis Heart Disease STD Asthma High Blood Pressure Scoliosis Bone Fracture Kidney Sinusitis Cancer Low Blood Pressure Spinal Disc Disease Diabetes Multiple Sclerosis Thyroid Emotional Disorder Polio Tuberculosis Epilepsy Prostate Ulcer HIV
Surgeries and Medications:
Signature:

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