Rubertchiropractic.com - Auto Accident History

Which clinic are you inquiring about?

Name

First NameLast Name

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone

Please enter a valid phone number.Format: (000) 000-0000.

Text Reminders:

Cell Phone Provider (needed for text reminder)

Date of Birth

Date

Age

Social Security #

Date of Accident/Injury

Date

Other

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?

Were there any witnesses?

Were you?

Number of People in the Vehicle

Number of People in Other Vehicle

What direction were you headed?

Name of the Street:

Where was the vehicle struck?

Were you wearing a seatbelt?

Were you wearing the shoulder strap?

Does the car have air bags?

Were the airbags deployed?

Were you knocked unconscious?

If yes, for how long?

Were you taken to the hospital/clinic?

Where?

Were the police called?

Is there a report available?

Have you seen other doctors for this accident?

Please List:

In your own words, please describe the accident:

Did you have any physical complaints before the accident?

If yes, please list:

What were your symptoms/complaints…

Immediately after the accident?

Later that day?

Currently?

Since the injury occurred, have your symptoms:

Do you have any previous illnesses relating to this case?

Have you had an accident/injury before?

If yes, please list and describe (date, type, etc.):

Do you notice any activity restrictions as a result of the accident/injury?

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:

Date:

Date

AUTO ACCIDENT HISTORY

ACCIDENT DETAILS