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Have you been injured in a CAR ACCIDENT?
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If this visit is related to a car accident, check box or slide switch (If no, skip to Reason for Visit)
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Date of Accident (mm/dd/yyyy)
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Your Vehicle Information
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Driver of your car?
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Registered Owner
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Insurance Company
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Insurance Phone Number
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Claims Adjuster
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Claim Number
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Policy Number
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Insurance Company Address
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Make
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Model
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Year
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Estimated Damage (leave out dollar sign)
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Do you have Med-Pay on your auto policy?
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If yes, what is your policy limit?
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Other Vehicle Information
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Driver of other car
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Registered Owner
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Insurance Company of other car
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Phone Number
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Claims Adjuster
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Claim Number
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Policy Number
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Make
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Model
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Year
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Accident Facts
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Were you injured in this accident?
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Which city and state did the accident occur?
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Cross streets?
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Driver/Passenger?
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Where was your vehicle struck?
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Road conditions
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Wearing seatbelt?
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Was your vehicle stopped at impact?
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Foot on brake? (drivers only)
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After struck, did your car hit another car/?
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Speed of your vehicle
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Speed of the other vehicle
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Did you brace yourself?
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Which direction were you looking?
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Air bags deployed?
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Body areas that struck (select all that apply)
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Did you lose consciousness?
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If blacked out, how long?
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Did police come to the scene?
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Police report filed?
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Have you received treatment prior to this visit?
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If so, where did you get treatment?
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How did you get to treatment?
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When did you get treatment? (if applicable)
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Imaging and treatment? (select all that apply)
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Additional treatment?
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Are you taking medications related to the accident?
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If so, which medications?
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Getting better/worse?
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Attorney Information
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Have you hired an attorney?
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If yes, please provide attorney name
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If no, would you like us to refer you to an attorney?
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Reason For Visit
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Your problem(s) today the result of ANY accident?
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Please explain what type of accident:
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Please make a selection in EACH box for your WORST area of pain.
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Where is your WORST pain?
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Your WORST pain SEVERITY?
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Your WORST pain FREQUENCY?
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What does your WORST pain feel like?
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Now make selections for EACH other area of pain you have.
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(Please make sure to fill out every section for each pain area.)
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Pain Area #2 (be specific)
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Pain Area #2 Severity
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Pain Area #2 Frequency
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Pain Area #2 Quality (select all that apply)
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Pain Area #3 (be specific)
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Pain Area #3 Severity
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Pain Area #3 Frequency
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Pain Area #3 Quality (select all that apply)
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Pain Area #4 (be specific)
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Pain Area #4 Severity
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Pain Area #4 Frequency
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Pain Area #4 Quality (select all that apply)
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Pain Area #5 (be specific)
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Pain Area #5 Severity
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Pain Area #5 Frequency
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Pain Area #5 Quality (select all that apply)
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Pain Area #6 (be specific)
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Pain Area #6 Severity
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Pain Area #6 Frequency
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Pain Area #6 Quality (select all that apply)
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Pain Area #7 (be specific)
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Pain Area #7 Severity
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Pain Area #7 Frequency
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Pain Area #7 Quality (select all that apply)
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Other Areas of Pain
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Other Pain Area (please explain)
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Other Pain Area Severity
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Other Pain Area Frequency
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Other Pain Area Quality (select all that apply)
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What caused your pain?
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How long have you had pain?
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What does this pain prevent you from doing?
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What makes your pain better?(choose all that apply)
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What makes your pain worse?
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Are you receiving treatment from another doctor?
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If yes, by whom? (name and title)
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Are you pregnant? (women only)
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Who is your primary care doctor? (if applicable)
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Systems Review (select all that apply)
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System Review - General
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Eyes, ears, nose, throat
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Skin
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Pulmonary/Lungs
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Muscle/Joint/Bone
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Neurologic
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