Motor Vehicle Accident History - Greensboro

Automobile/Personal Insurance Accident or Work Comp Questionnaire

About this Patient

Marital Status*
Please select one option

About the Spouse 

Emergency Contact

Information about the Accident / Present Injury

Did you require post-accident hospitalization?*
Please select at least one option
Have you ever had any complaints in the involved area before?*
Please select at least one option
Before the injury were you capable of working on an equal basis with others your age?*
Please select at least one option
Are your work activities restricted as a result of this accident?*
Please select at least one option
Since this injury are your symptoms are:*
Please select at least one option

Insurance Information

Driver of other vehicle (if any):

Driver of vehicle in which you were injured (if applicable):

Have you retained an attorney?*
Please select at least one option

Outcome Assessment

Check symptoms you have noticed since the accident:*
Please select at least one option

Using the scale below for reference, please answer the following questions as accurately as possible

Overall frequency of complaint (Please check only one)
Do your symptoms increase while performing your normal work duties?
If yes, please select the amount below that you feel your symptoms increase at work:
Has this condition
Does this condition interfere with
Has this condition occurred before?*
Please select one option
Have you seen other doctors for this condition?*
Please select one option

Place an X on the image below, where you feel pain, numbness or tingling:

Mark your Pain Point
Please mark all that describe the quality of your pain

Activities of Daily Living

Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:

Going from Sitting-to-Standing*
Please select at least one option
Climbing Stairs*
Please select at least one option
Please select at least one option
Extended Computer Use*
Please select at least one option
Getting Dressed*
Please select at least one option
Lifting Children/Groceries*
Please select at least one option
Sexual Activities*
Please select at least one option
Please select at least one option
Static Sitting*
Please select at least one option
Static Standing*
Please select at least one option
Please select at least one option
Please select at least one option
Yard Work*
Please select at least one option

Experience with Chiropractic 

Have you been adjusted by a chiropractor before?*
Please select one option
Has any adult in your family seen a Chiropractor?*
Please select one option
Has any child in your family seen a Chiropractor?*
Please select one option

Awareness of Chiropractic Principles 

Were you aware that...

Doctors of Chiropractic work with the nervous system?*
Please select one option
The nervous system controls all bodily functions and systems?*
Please select at least one option
Chiropractic is the largest natural healing profession in the world?*
Please select one option
If Chiropractic care starts at birth, you can achieve a higher level of health throughout life?*
Please select at least one option

Goals for my Care 

People see chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of their pain, and others for correction of whatever is malfunctioning in their bodies. Please check the type of care desired so that we may be guided by your wishes whenever possible.

Medications I Now Take:

Please select at least one option

Health Habits

Do you smoke or vape?*
Please select one option
Do you drink alcohol?*
Please select one option
Do you exercise regularly?*
Please select one option
Do you drink coffee?*
Please select one option

Health Systems Review

Please check each of the conditions that you have experienced within the past 6 months. 

Health Conditions:*
Please select at least one option


Are you pregnant?
Are you taking birth control?
Are you nursing?
Do you experience painful periods?
Do you have irregular cycles?

Nutrition and self-care are just two components of optimal wellness. 
Please let us know what you are currently doing for your health.

Things I do currently to support my health include:
On average, how many hours do you spend sitting per day?*
Please select one option

Authorization for Care & Notice of Privacy

I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate.

I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition, we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances. If you would like a more detailed explanation, one will be provided to you. In addition, you will find we have placed several copies in report folders labeled 'HIPAA' on tables in the reception. Once you have read this notice, please sign the last page, and return only the signature page to our front desk receptionist. Keep this page for your records.


  1. Treatment purposes- discussion with other health care providers involved in your care
  2. Inadvertent disclosures- open treating area mean open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room.
  3. For payment purposes - to obtain payment from your insurance company or any other collateral source.
  4. For workers' compensation purposes- to process a claim or aid in investigation
  5. Emergency- in the event of a medical emergency we may notify a family member
  6. For Public health and safety - in order to prevent or lessen a serious or eminent threat to the health or safety of a person or general public.
  7. To Government agencies or Law enforcement – to identify or locate a suspect, fugitive, material witness or missing person.
  8. For military, national security, prisoner and government benefits purposes.
  9. Deceased persons –discussion with coroners and medical examiners in the event of a patient's death.
  10. Telephone calls or emails and appointment reminders -we may call your home and leave messages regarding a missed appointment or apprize you of changes in practice hours or upcoming events.
  11. Change of ownership- in the event this practice is sold the new owners would have access to your PHI.


  1. To receive an accounting of disclosures
  2. To receive a paper copy of the comprehensive "Detail" Privacy Notice
  3. To request mailings to an address different than residence
  4. To request Restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.
  5. To inspect your records and receive one copy of your records at no charge, with notice in advance
  6. To request amendments to information. However, like restrictions, we are not required to agree to them.
  7. To obtain one copy of your records at no charge, when timely notice is provided (72 hours). X-rays are original records and you are therefore not entitled to them. If you would like us to outsource them to an imaging center, to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost. Your signature below gives us permission to send your medical records and x-rays to you on an encrypted server to the email that you provide to us.


I have received a copy of the Privacy Notice I understand my rights as well as the practices duty to protect my health information, and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this 'Notice of Privacy Practice" at a time in the future and will make the new provisions effective for all information that it maintains past and present.

Informed Consent to Chiropractic Care:

Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.

I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risks are most often very minimal, in rare cases, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke, which occurs at a rate between once per one million to one per two million, have been associated with chiropractic adjustments.

I understand there may be treatment options available for my condition other than chiropractic procedures. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. 

Treatment objectives as well as the risks associated with chiropractic adjustments and, all other procedures provided  have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.

Consent for Diagnostic X-rays:

During your examination, the doctor may feel that x-rays will be needed in order to diagnose your condition. In addition, they may be required in order to administer treatment. 

Females Only:

  • I understand that if I am pregnant and have x-rays taken which expose my lower torso to radiation, it is possible to injure the fetus.
  • I am aware that the ten (10) days following the onset of a menstrual period are generally considered to be safe for x-ray exams.
  • By my signature below I am acknowledging the risks of hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. 
Please select one of the following:

Thank you for taking the time to fill out this form.