American Medical Injury Centers Intake

American Medical Injury Centers Intake

Complete this intake and accident/injury questionnaire with your medical history, accident details, and symptoms.
Patient Demographics and Contact Info
First Name
Middle Name
Last Name
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Sex
Marital Status
Date of Birth

MonthDayYear
Date
Age
Patient Email
example@example.com
Photo Identification (License, ID, or Passport)

Cancelof
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Accident Type
Accident Type
Date of Accident

MonthDayYear
Date
Attorney Details
Attorney Firm Name
Attorney Name

First NameMiddle NameLast Name
Attorney Phone
Please enter a valid phone number.Format: (000) 000-0000.
Accident and Vehicle/Impact Details
Your position in automobile
Your Vehicle Year/Make/Model
Estimated Speed (MPH)
Vehicle Motion
Point of Impact
Damage Estimate ($)
Describe how the accident happened
Accident Happened While on the Job?
Name of Person Driving (If Not Patient)
Other Vehicle Year/Make/Model
Other Vehicle Motion
Other Vehicles Involved
Other Vehicles Description
Were you wearing a seatbelt?
Did airbags deploy?
Did your seat bend or break?
Your body position at the time of impact
Your head direction at impact
Were you leaning forward at impact
Did you brace before impact or were you relaxed?
Did any of these parts of your body hit against anything in the vehicle?

Other
Immediate Symptoms and Initial Treatment
Immediate feelings after the accident

Other
If other, please specify immediate feelings
Did you lose consciousness?
If yes, how long were you unconscious?
Were you able to exit the vehicle on your own?
Did an ambulance come to the scene?
Did you receive treatment at the scene?
Describe the treatment received at the scene
Were you transported to a hospital?
Hospital name
How were you transported?
Were you admitted to the hospital?
How long did you stay in the hospital?
What treatments did you receive at the hospital?
Other doctors seen (names and details)
Medical History
Medications taken before the accident
Allergic to medications?
List medication allergies
Major surgeries and year performed
Major falls or accidents in the past 3 years
Do you suffer from any of these conditions?

Other
Social History
Employment status
Employer
Type of work
Do you smoke cigarettes or use tobacco?
Do you use illegal substances?
Do you consume alcohol?
Are you HIV positive?
Date of last menstrual cycle

MonthDayYear
Date
Possibility of pregnancy?
Pregnancy due date

MonthDayYear
Date
Currently taking birth control pills?
Currently taking hormone replacements?
Symptoms and Functional Impact

Rivermead Post-Concussion Symptom Scale

Rows	Not a problem	Mild	Moderate	Severe
Headaches
Feelings of dizziness
Nausea and/or vomiting
Noise sensitivity
Sleep disturbance
Fatigue, tiring more easily
Being irritable, easily angered
Feeling depressed or tearful
Feeling frustrated or impatient
Forgetfulness, poor memory
Poor concentration
Taking longer to think
Blurred vision
Light sensitivity

Rivermead Concussion Score
Chief complaints - Head/Neck

Other
Chief complaints - Back/Trunk

Other
Chief complaints - Upper extremity

Check side(s) that hurt
Shoulder pain
Arm pain
Elbow pain
Wrist pain
Hand pain
Chief complaints - Lower extremity

Check side(s) that hurt
Hip pain
Thigh pain
Knee pain
Ankle pain
Foot pain
Patient signature
Date signed

MonthDayYear
Date
Patient under 18 years old
Minor patient name

First NameMiddle NameLast Name
Parent or legal guardian name

First NameMiddle NameLast Name
Pharmacy information

NameAddressTelephone number
Parent or legal guardian signature
Parent or legal guardian date signed

MonthDayYear
Date
Should be Empty:

American Medical Injury Centers Intake

Patient Demographics and Contact Info

Accident Type

Attorney Details

Accident and Vehicle/Impact Details

Immediate Symptoms and Initial Treatment

Medical History

Social History

Symptoms and Functional Impact

Chief complaints - Upper extremity

Chief complaints - Lower extremity

Patient under 18 years old