Motor Vehicle Accident History - High Point | Chiropractor in Winston Salem, NC

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New Patients
- Online Forms
- Payment Options
Locations
Blog
Contact Us

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Motor Vehicle Accident History - High Point

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About Us
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Auto Accident
New Patients
- Online Forms
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Locations
Blog
Contact Us

Motor Vehicle Accident History - High Point

First Name*

Last Name*

ADDRESS:

CITY:

STATE/ZIP CODE:

CELL PHONE NUMBER:*

SOCIAL SECURITY NUMBER:

DATE OF BIRTH:

AGE:

GENDER:

EMERGENCY CONTACT NAME:

EMERGENCY CONTACT PHONE NUMBER:

EMPLOYER NAME:

EMPLOYER ADDRESS:

DATE OF ACCIDENT:

TIME OF ACCIDENT:

DRIVER

PASSENGER

FRONT SEAT 

BACK SEAT

NUMBER OF PEOPLE IN THE CAR:

NAMES OF PEOPLE IN THE CAR WITH YOU:

NORTH 

SOUTH 

EAST 

WEST

NORTH SOUTH EAST WEST

NORTH 

SOUTH 

EAST 

WEST

BEHIND 

FRONT 

LEFT SIDE

RIGHT SIDE

WERE YOU KNOCKED UNCONSCIOUS?

YES

NO

YES

NO

YES

NO

DID YOU HIT YOUR HEAD?

WHERE WERE YOU TAKEN AFTER THE ACCIDENT?



YES

NO



YES_2

NO_2

YESNO

YES_3

NO_3

WERE THE POLICE ON THE SCENE?WAS A REPORT FILED?DO YOU HAVE A COPY?



YES_4

NO_4

IMPROVING 

GETTING WORSE

GETTING BETTER

YES

NO

YES

DATE YOU RETURNED TO WORK:



YES_5

NO_5



YES_6

NO_6



YES_7

NO_7

YESNO

AUTO INSURANCE COMPANY NAME:

ADJUSTER NAME:

ADJUSTER PHONE NUMBER:

POLICY NUMBER:

CLAIM NUMBER:

HOME PHONE NUMBER:

YES

NO

What is your chief complaint

Additional complaint:

When did your symptoms first appear

most discomfort/severe: 0

Dull

Throbbing

Ache

Shooting

Tingling

P1 Tingling

Stiff

P1 Stiff

P1 Work

P1 Sleep

P1 Daily Routine

Standing

Walking

Bending

Lying Down

P1 Lying Down

P1 Getting Worse

P1 Comes Goes

P1 Unbearable

P1 Head

P1 Neck

P1 Mid Back

P1 Low Back

L.ArmR.Leg

L.Leg

PI Stays Same

P2 Unbearable

P2 Comes Goes

P2 Stays Same

P2 Getting Worse

Dull

Throbbing

Ache

Shooting

Tingling

P2 Tingling

Stiff

P2 Stiff

P2 Work

P2 Sleep

P2 Daily Routine

P2 Sitting

P2 Standing

P2 Walking

P2 Bending

P2 Lying Down

P2 Head

P2 Neck

P2 Mid Back

P2 Low Back

P3 Getting Worse

P3 Stays Same

P3 Comes Goes

P3 Unbearable

Dull

Throbbing

Ache

Shooting

Tingling

P3 Tingling

Stiff

P3 Stiff

P3 Work

P3 Sleep

P3 Daily Routine

Standing

Walking

Bending

Lying Down

P3 Lying Down

P3 Head

P3 Neck

P3 Midback

P3 Low Back

Shoulder

Hip

Leg

Foot

Arm

Patient Name ________________________________________________ Date

1 –What is your pain RIGHT NOW?

2 –What is your TYPICAL or AVERAGE pain?

3 –What is your pain level AT ITS BEST (How close to "0" does your pain get at its best)?

4 –What is your pain level AT ITS WORST (How close to "10" does your pain get at its worst)?

FEVEROTHER:

COMMENTS [1]

COMMENTS [2]

COMMENTS [3]

COMMENTS [4]

PLEASE PROVIDE ANY OTHER PERTINENT INFORMATION YOU THINK WE SHOULD KNOW:

DESCRIBE THE ACCIDENT IN YOUR OWN WORDS:

PATIENT SIGNATURE:

HEADACHE

NECK PAIN

NECK STIFFNESS

SLEEPING PROBLEMS

BACK PAIN

NERVOUSNESS

TENSION

IRRITABILITY

CHEST PAIN

DIARRHEA

CONSTIPATION

FEVER

DIZZINESS

HEAD SEEMS HEAVY

PINS & NEEDLES IN ARMS

PINS & NEEDLES IN LEGS

NUMBNESS IN FINGERS

NUMBNESS IN TOES

SHORTNESS OF BREATH

FATIGUE

DEPRESSION

FEET FEEL COLD

HANDS FEEL COLD

COLD SWEATS

LIGHT BOTHERS EYES

LOSS OF MEMORY

EARS RING

FACE FLUSHED

BUZZING IN EARS

LOSS OF BALANCE

FAINTING

LOSS OF SMELL

LOSS OF TASTE

UPSET STOMACH

OTHER:

Comment Numbness

Comment Pain

T=Tingling S=Stiffness/Soreness

Comment Tingling

Comment Stiff Sore

RELATIONSHIP TO PATIENT:

DATE:

Patient or Guardian Signature:

________________________________________________________________________ DATE

SIGNATURE:

PATIENT NAME (PLEASE PRINT):

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

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