AUTO ACCIDENT INFORMATION FORM

Legault Chiropractic Health Center

(Confidential Information)

PLEASE ANSWER ALL QUESTIONS COMPLETELY

Dear Patients: We need this information because we care enough to want to know, and your answers will help us determine if chiropractic care 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 accurate as possible while completing this form. Thank You.

Personal Questions

Patient's Name                                             Today's Date    

Home Phone      Cell Phone #     Work Phone  

Permanent Address   Apt #         City 

State/Prov.    Zip/Postal Code/Country   E-mail Address  NOTE: Legault Chiropractic does NOT sell nor share your e-mail address with Any outside parties, except as You request. We may send you an E-Newsletter once a month &/or a notice of  any "Specials of the Month" as they may interest you.

Local Street Address (if different)  Local Tel #  

City     State         Zip 

Gender    . Male Female       Marital Status . Single Married Civil Partner Widowed Separated Divorced   Date of Birth     Occupation   RETIRED

Place of Employment Social Security #        Name of Spouse  

Insurance Company  

Name of Children & Age 

WHOM may we be Thank for Referring You to our office? 

Have you EVER had Chiropractic Care in the Past?         . Yes No     If "YES" Please indicate When? 

Name of your prior Chiropractor     Where?  and Why did you stop?

Was it a Great experience?      . Yes No       Did they take Spinal X-rays?     Yes . No I can not recall       Approx. date of Last Spinal X-rays 

___________________________________________________________________________________________________________________________________________________________________________

Accident Questions

Date of the Accident   Time AM  PM Weather Conditions

Please explain in DETAIL how your accident happened

You were heading:  North  South  East   West on  Highway  Street

Were you struck from: Behind Front  Right Side Left Side Other

Were you the: Driver Front Passenger Back Passenger Using A Seat belt Air Bag Deployed Other Protective Devices

Were you knocked unconscious? Yes No If so, for how long? 

Where did you feel pain immediately after the accident?  

Where did you go immediately after the accident? Hospital Home Work Other

If hospital, Name  Were you taken by ambulance? Yes No

Were you seen by any doctor after your accident? Yes No If so, Doctors name

How often did you see the doctor? How long?

What was the diagnosis? What treatment was given?

Do you authorize this office to request your charts and/or send them a report? Yes No

If Yes, address of doctor  

Have you ever had any complaints in the involved area(s) before this accident? Yes No Explain

Before this injury were you capable of working on an equal basis with others your age? Yes No

Are your work activities restricted as a result of this accident? Yes No

Since this injury are your Symptoms: Improving Getting Worse Same

Present Complaint(s)

Neck Pain Low Back Pain Headaches

Upper Back Pain Numbness/Tingling TMJ

Mid Back Pain Sinus Problems Dizziness

Side or Rib Pain Difficulty Breathing Nervousness

Shoulder/Arm/Hand Pain Digestive Problems Confusion/Depression

Hip/Leg/Foot Pain Urinary Problems  Diarrhea/Constipation

Vision Problems Loss of Sleep

Broken Bones: No Yes

Other:

Which, if any, of the above complaints bothered you before this accident occurred?

Females Only: Are you Pregnant? Yes No Menstrual Problems? Yes No Breast Pains? Yes   No

Past History: Have you ever had ANY surgery? Tonsils Appendix Gall Bladder Heart

Cancer Spinal Surgery Other Surgeries

Review Of Body Systems: (Please Check Off Any System Which Gives You A Problem Or For Which You Are Taking Medications.)

Heart/Circulation (High Blood Pressure) Lungs/Respiratory (Asthma)

Gastrointestinal (Heart Burn/Constipation/Diarrhea) Blood/Lymphatic (Leukemia/HIV Positive)

Neurological (Numbness/Paralysis) Endocrine/Hormones (Diabetes/Thyroid)

Eyes (Wears Glasses/Glaucoma/Other) Immune System (Frequent Colds/Flu/Fevers)

Ears/Nose/Throat/Mouth Genito/Urinary (Reproductive System/Bladder)

Psychiatric (Depression/Extreme Tension) Skin (Boils/Pimples/Cancer)

More Illnesses:

List Any Medications You Presently Take:

FEES ARE DUE WHEN SERVICES ARE RENDURED, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE. (A COPY OF YOUR DRIVERS LICENSE IS MANDATORY)

Driver of Vehicle: Were The Police Notified? Yes No

Have You Notified YOUR Insurance Company? Yes No Insurance Company Name:

Policy Number: Claim Number:

Other Vehicle(if applicable):

Name of Driver: Name of Ins.: Policy #:

Person responsible for this account: Self Insurance

Do you have an attorney for this case? Yes No If so, Name of Attorney:

Attorney’s Address: Telephone Number:

Privacy Statement: We at the Legault Chiropractic Health Center, honor and respect all of our patients and their right to privacy. It is the regular policy of this office to minimize disclosure or dissemination of any personal information on any/all of our patients. Neither your name, address, phone number(s), nor health/financial records will be used, nor shared with any outside agent, except as expressed and authorized by you. (example- your spouse and or insurance company) or as required by law.

I, the undersigned, am requesting to be examined and treated by the Legault Chiropractic Health Center for the fore mentioned Auto Accident Related Injuries and complaints.

Signature: Date:

I certify that the above electronic signature will stand in place for my written signature.

I, hereby authorize the Legault Chiropractic Health Center to disclose and or release my private health and financial information to and or for the purpose of payment, coordination of my care and or to transport said information for me in my absence.

Signature of Patient: Date:

I certify that the above electronic signature will stand in place for my written signature.

(I understand and agree that it is my responsibility to notify the Legault Chiropractic Health Center, in writing, if I wish to discontinue and or change the above authorization.)

To PRINT  Click 'CTRL' + 'P' at same time

Please NOTE: At this time, this form can NOT be Transmitted Electronically. Therefore, PLEASE PRINT this FORM,   SIGN it where indicated, & BRING IT with YOU when you COME IN for your SCHEDULED APPOINTMENT.

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