Legault Chiropractic Health Center

(Confidential Information)


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           Marital Status        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?            If "YES" Please indicate When

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

Was it a Great experience?           Did they take Spinal X-rays?          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


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:


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.)



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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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