restorativespineandjoint.com - Auto Accident Form

Describe how you felt:

During the accident

Immediately after the accident

Later that day

The next day

Please select 'Yes' or 'No' with your current symptoms:

	Yes/No	Right	Left
Jaw / TMJ pain
Headache
Neck pain
Mid back pain
Radiating pain to head
Radiating pain to shoulder / arm
Shoulder / arm pain
Arm tingling / numbness
Elbow pain
Wrist pain
Hand pain
Hand tingling / numbness
Low back pain
Sacroiliac pain
Radiating pain to hip / leg
Hip / leg pain
Leg tingling / numbness
Knee pain
Ankle pain
Foot pain
Foot tingling / numbness
Muscle spasms / soreness
Anxiety / depression
Dizziness / fainting
Fatigue
Ringing / buzzing in the ears
Visual disturbances

Other

List any other present complaints and symptoms

Before the accident did you have any of your present complaints?

YesNo

If yes, describe

Have you lost time from work as a result of this accident?

YesNo

If yes, list dates lost

Type of employment

Insurance company of party responsible for payment

Claim #

Phone Number

Please enter a valid phone number.

Adjustor

Your automobile insurance company

Agent

Phone Number

Please enter a valid phone number.

Do you have Med-Pay coverage?

YesNoI'm not sure

Your group health insurance company

Policy #

Phone Number

Please enter a valid phone number.

Have you retained an attorney?

YesNo

If yes, who?

Phone Number

Please enter a valid phone number.

Assignment Of Benefits

By signing this form you authorize your insurance company to make payments directly to this clinic; however, you are ultimately responsible for payment. If your insurance company sends checks to you, you are legally obligated to bring them to us.

Signature of patient or legal guardian

Date

SUPPLEMENTAL HISTORY: AUTO ACCIDENT

Insurance companies involved: