Automobile Accident Questionnaire

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Automobile Accident Questionnaire

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 what kind of care you will need. If we do not sincerely believe your condition will respond to chiropractic care, we will refer you for outside care accordingly. In order for us to understand your condition properly, please be as neat and accurate as possible while completing this form. Thank you from Doctor and staff.

Date
Name*

Sex
Marital Status

Date of Birth
Home Phone*

Address

City
State
Zip

Occupation
Who referred you to our office?

Social Security #
Bus. Phone
Company Name

Spouses Name
Spouse’s SS #
Employer

Email* (to receive health information from our office)

Please explain in detail how your accident happened

Were you heading North South East West on (street or hwy)?

Other vehicle was headed North South East West on (street or hwy)

Have you retained an attorney?
Litigation?

If so, name and address

Give time and date present injury occurred

Where did you feel pain immediately after the accident?

Did you return to work?
If so, date returned to work

Did you consult any other doctor?
If so, doctor’s name

What treatments did you receive?

Have you ever injured this area before?
If so when?

If injured before did you lose time from work?

If you lost time from work with injuries prior to this injury give name of doctor or doctors consulted

Do any other diseases or accidents affect your employment?

If so, explain

Are your work activities restricted as a result of this accident?
Since this injury are your symptoms

Have you ever had an Automobile Accident claim before?
If so, when?

SPECIFICS ABOUT YOUR ACCIDENT:
What was your position in the vehicle?
What type of vehicle were you driving?

What speed were you traveling at the time of the accident?
Who hit who?

What was your vehicles point of impact?
What speed was the other vehicle traveling at the time of the accident?

What was the other vehicle’s point of impact?
Were you wearing seat restraint’s?

What position were your vehicle head rests in?
Did your vehicle air bags deploy?

Where you prepared for the impact?

What position was your body in just prior to impact?

What happened to your body at impact?

What was your emotional state after the accident?

Did you receive medical attention at the scene of the accident? If so, what?

Where did you go immediately after the accident? (i.e. ER, doctor, home, work, etc.)

Did you hit any other body parts on parts of the vehicle at impact? If so, which?

HEALTH QUESTIONNAIRE:
Height:
Weight:

When was your blood pressure last taken?
What was your blood pressure?

Do you have a family history of High Blood Pressure?

Please indicate for by use of the following codes:
1-never had
2-previously had
3-presently have

MUSCULO-SKELETAL SYSTEM:
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:
Bladder trouble:
Excessive urination:
Scanty urination:

Painful urination:
Discolored urine:

FEMALE:
Vaginal discharge:
Vaginal bleeding:
Vaginal pain:

Breast pain:
Lumps in breast:
Are you pregnant?

GASTRO-INTESTINAL SYSTEM:
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:
Numbness:
Loss of feeling:
Paralysis:

Dizziness:
Fainting:
Headaches:

Muscle jerking:
Convulsions:
Forgetfulness:

Depression:

CARDIO-VASCULARRESPIRATORY SYSTEM:
Chest pain:
Pain over heart:
Difficulty breathing:

Persistent cough:
Coughing phlegm:
Rapid heartbeat:

Blood pressure problems:
Heart problems:
Lung problems:

Varicose veins:

EYE, EAR, NOSE, AND THROAT:
Eye strain:
Eye inflammation:
Vision problems:

Ear pain or noises:
Hearing loss:
Ear discharge:

Nose pain:
Nose bleeding:
Difficult breathing thru nose:

Dental problems:
Popping noise in jaw:
Sore mouth:

Sore throat:
Difficulty swallowing:
Difficult speech:

AUTOMOBILE INSURANCE INFORMATION
Name of policy holder

Insurance Co.
Phone #

Address

City
State
Zip

Date of Injury
Policy No.
Claim No.

Name of Adjustor

ADDITIONAL INSURANCE (Secondary Insurance)
Name of insured
Relationship to Patient

Birth date
Insurance Co.

Phone #
Group #
Employer #

Insurance Co. Address

City
State
Zip

How much is your deductible?
How much have you used?
Max. annual benefit?

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