healthchiro.com - Auto Accident Questionnaire

Automobile Accident Questionnaire

Please answer all questions completely
Dear Patient: This information is considered confidential. We need this information because we care enough to want to know, and your answers will help us determine if chiropractic can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. In order for us to understand your condition properly, please be as neat and accurate as possible while completing this form. Thank you.
Name

First NameLast Name
Sex
Marital Status
Date of Birth

MonthDayYear
Date
Home Phone
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
(include if student, child, housewife, unemployed, retired)
Who referred you to our office?
Social Security #
Business Phone
Please enter a valid phone number.
Company Name
Location
Spouse's First Name
Spouse's Social Security #
Spouse's Employer
Location
Please explain in detail how your accident happened
Insurance Co.
Policy No.
Claim No.
Driver of other vehicle (if any)
Name
Insurance Company
Policy No.
Driver of vehicle in which you were injured (if applicable)
Name
Insurance Company
Policy No.
Name of your insurance adjustor.
Have you retained an attorney?

YesNo
If so, his name and address
You were heading

NorthEastSouthEast
Other vehicle was headed

NorthEastSouthEast
Were police notified?

YesNo
Were you knocked unconscious?

YesNo
If so, for how long?
You were struck from

BehindFrontLeft sideRight side
You were

DriverPassengerFront seatBack SeatUsing seat beltsOther protective devices
What were the time and date of present injury?
Where did you feel pain immediately after the accident?
Where were you taken after the accident?
What treatment was given?
Was any other doctor consulted after your accident?

YesNo
If so, what was the doctor's name?
Also mention D.C., M.D., D.O., D.D.S.
What was the diagnosis?
What treatment was given?
How often did you see the doctor?
How long did you see the doctor?
Have you ever had any complaints in the involved area before?

YesNo
If so, what were the complaints?
Before the injury were you capable of working on an equal basis with others your age?

YesNo
Are your work activities restricted as a result of this accident?

YesNo
Since this injury are your symptoms

Improving?Getting worse?Same?

HEALTH QUESTIONNAIRE

Please indicate for each of the questions below your experience

MUSCULO-SKELETAL SYSTEM

	Never had	Previously had	Presently had
Low back problems
Pain between shoulders
Neck problems
Arm problems
Leg problems
Swollen joints
Painful joints
Stiff joints
Sore muscles
Weak muscles
Walking problems
Ruptures
Broken bones

GENITO-URINARY SYSTEM

	Never had	Previously had	Presently had
Bladder trouble
Excessive urination
Scanty urination
Painful urination
Discolored urine

FEMALE

	Never had	Previously had	Presently had
Vaginal discharge
Vaginal bleeding
Vaginal pain
Breast pain
Lumps on breast

Are you pregnant?

YesNo

GASTRO-INTESTINAL SYSTEM

	Never had	Previously had	Presently had
Poor appetite
Excessive hunger
Difficult chewing
Difficult swallowing
Excessive thirst
Nausea
Vomiting food
Vomiting blood
Abdominal pain
Diarrhea
Constipation
Black stool
Bloody stool
Hemorrhoids
Liver trouble
Gall bladder problems
Weight trouble

NERVOUS SYSTEM

	Never had	Previously had	Presently had
Numbness
Loss of feeling
Paralysis
Dizziness
Fainting
Headaches
Muscle jerking
Convulsions
Forgetfulness
Confusion
Depression

CARDIO-VASCULAR RESPIRATORY

	Never had	Previously had	Presently had
Chest pain
Pain over heart
Difficult breathing
Persistent cough
Coughing phlegm
Coughing blood
Rapid heartbeat
Blood pressure problems
Heart problems
Lung problems
Varicose Veins

EYE, EAR, NOSE, AND THROAT

	Never had	Previously had	Presently had
Eye strain
Eye inflammation
Vision problems
Ear pain
Ear noises
Ear discharge
Hearing loss
Nose pain
Nose bleeding
Nose discharge
Difficult breathing thru nose
Sore gums
Dental problems
Sore mouth
Hoarseness
Difficult speech

Please mark your areas of pain on the figures below.
Patient's Signature

Clear
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