Rubertchiropractic.com - Auto Accident History

AUTO ACCIDENT HISTORY
Name

First NameLast Name
Gender

MaleFemales
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Text Reminders:

YESNO
Cell Phone Provider (needed for text reminder)
Date of Birth

MonthDayYear
Date
Age
Social Security #
Date of Accident/Injury

MonthDayYear
Date
AutoOther
Name of Your Auto Insurance
Claim #
Name of Other Driver
His/Her Insurance
Ins. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who was at fault?
Who was given a ticket?
Have you retained an attorney/Do you plan to?

YesNo
Were there any witnesses?

YesNo
ACCIDENT DETAILS
Were you?

DriverPassengerFront SeatBack Seat
Number of People in the Vehicle
Number of People in Other Vehicle
What direction were you headed?

NorthSouthEastWest
Name of the Street:
Where was the vehicle struck?

BackFrontLeft SideRight Side
Were you wearing a seatbelt?

YesNo
Were you wearing the shoulder strap?

YesNo
Does the car have air bags?

YesNo
Were the airbags deployed?

YesNo
Were you knocked unconscious?

YesNo
If yes, for how long?
Were you taken to the hospital/clinic?

YesNo
Where?
Were the police called?

YesNo
Is there a report available?

YesNo
Have you seen other doctors for this accident?

YesNo
Please List:
In your own words, please describe the accident:
Did you have any physical complaints before the accident?

YesNo
If yes, please list:
What were your symptoms/complaints…
Immediately after the accident?
Later that day?
Currently?
Since the injury occurred, have your symptoms:

ImprovedWorsenedStayed the Same
Do you have any previous illnesses relating to this case?
Have you had an accident/injury before?

YesNo
If yes, please list and describe (date, type, etc.):
Do you notice any activity restrictions as a result of the accident/injury?

YesNo
Please describe:
Any other pertinent information:
We invite you to discuss frankly with us any questions regarding services. The best health services are based on a friendly, mutual understanding between provider and patient. If your account is not paid within 90 days of the date of service, and no financial arrangements have been made, you will be responsible for any expenses incurred in collecting your account.

I understand the above information and guarantee this form was completed correctly to the best of my knowledge. I understand it is my responsibility to inform this office of any changes in my health or insurance status.
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

AUTO ACCIDENT HISTORY

ACCIDENT DETAILS