"Auto Accident Form - Supplemental History"

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SUPPLEMENTAL HISTORY: AUTO ACCIDENT
Name _________________________________________________________________
Today's Date _____________________
Time _______________
am
pm
Date of accident _____________________
Time of accident _____________________
am
pm
Were you the:
Driver
Passenger in front seat
Passenger in back seat
Were you wearing a seat belt?
Yes
No
How many vehicles were involved in the accident?
One
Two
Three
Four
Other ___________________________
How many people were in your vehicle?
One
Two
Three
Four
Other ___________________________
Make and model of your vehicle ____________________________________________________________________________________________________________________
Make and model of the other vehicle ________________________________________________________________________________________________________________
What direction were you headed?
North
South
East
West
On what street? ______________________ In what city? _____________________________
In what county? ___________________
In what state? _____________________
Type of accident:
I was hit
I hit someone else
Rear-ended
Broadside
Head-on
Other ___________________________
Speed: Was your vehicle:
Stopped
Braking
Moving _____ mph (Approximately)
Forward
Backward
Speed: Was the other vehicle:
Stopped
Braking
Moving _____ mph (Approximately)
Forward
Backward
Visibility at the time of the accident:
Good
Poor
Fair
Draw on these diagrams how the accident happened:
Describe the accident in your own words: _____________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
Approximate damage done to the car you were in (dollar amount) $________________
Damage estimate from body shop not completed yet
Were you aware the accident was going to happen before impact?
Yes
No
Did you brace yourself before impact?
Yes
No
Head position at the time of impact?
Turned
Right
Left
Straight ahead
Looking back
Body position at the time of impact?
Turned
Right
Left
Straight ahead
Can you recall what parts of your head or body hit what parts of your car during the accident? ___________________________________________________________________
_______________________________________________________________________________________________________________________________________________
Could you move all your body parts after the accident?
Yes
No
If no, explain: _________________________________________________________________
_______________________________________________________________________________________________________________________________________________
As a result of the accident were you:
Shaky / upset
Disoriented / confused
Rendered unconscious
Have you suffered from memory loss since the accident?
Yes
No
If yes, describe: ____________________________________________________________
_______________________________________________________________________________________________________________________________________________
Were you hospitalized?
Yes
No
If yes, hospital _______________________________________________________________________________________
Have you been treated by a physician?
Yes
No
If yes, name _____________________________________________________________________________
What type of treatment? ___________________________________________________
How often? _________________________
Results ____________________________
Are you still being treated?
Yes
No
BROWN CHIROPRACTIC/ACUPUNCTURE, PC
PO BOX 25465 TEMPE, AZ 85285-5465
480-377-1226
SUPPLEMENTAL HISTORY: AUTO ACCIDENT
Name _________________________________________________________________
Today's Date _____________________
Time _______________
am
pm
Date of accident _____________________
Time of accident _____________________
am
pm
Were you the:
Driver
Passenger in front seat
Passenger in back seat
Were you wearing a seat belt?
Yes
No
How many vehicles were involved in the accident?
One
Two
Three
Four
Other ___________________________
How many people were in your vehicle?
One
Two
Three
Four
Other ___________________________
Make and model of your vehicle ____________________________________________________________________________________________________________________
Make and model of the other vehicle ________________________________________________________________________________________________________________
What direction were you headed?
North
South
East
West
On what street? ______________________ In what city? _____________________________
In what county? ___________________
In what state? _____________________
Type of accident:
I was hit
I hit someone else
Rear-ended
Broadside
Head-on
Other ___________________________
Speed: Was your vehicle:
Stopped
Braking
Moving _____ mph (Approximately)
Forward
Backward
Speed: Was the other vehicle:
Stopped
Braking
Moving _____ mph (Approximately)
Forward
Backward
Visibility at the time of the accident:
Good
Poor
Fair
Draw on these diagrams how the accident happened:
Describe the accident in your own words: _____________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
Approximate damage done to the car you were in (dollar amount) $________________
Damage estimate from body shop not completed yet
Were you aware the accident was going to happen before impact?
Yes
No
Did you brace yourself before impact?
Yes
No
Head position at the time of impact?
Turned
Right
Left
Straight ahead
Looking back
Body position at the time of impact?
Turned
Right
Left
Straight ahead
Can you recall what parts of your head or body hit what parts of your car during the accident? ___________________________________________________________________
_______________________________________________________________________________________________________________________________________________
Could you move all your body parts after the accident?
Yes
No
If no, explain: _________________________________________________________________
_______________________________________________________________________________________________________________________________________________
As a result of the accident were you:
Shaky / upset
Disoriented / confused
Rendered unconscious
Have you suffered from memory loss since the accident?
Yes
No
If yes, describe: ____________________________________________________________
_______________________________________________________________________________________________________________________________________________
Were you hospitalized?
Yes
No
If yes, hospital _______________________________________________________________________________________
Have you been treated by a physician?
Yes
No
If yes, name _____________________________________________________________________________
What type of treatment? ___________________________________________________
How often? _________________________
Results ____________________________
Are you still being treated?
Yes
No
BROWN CHIROPRACTIC/ACUPUNCTURE, PC
PO BOX 25465 TEMPE, AZ 85285-5465
480-377-1226
SUPPLEMENTAL HISTORY: AUTO ACCIDENT
Describe how you felt:
During the accident _______________________________________________________________________________________________________________________________
Immediately after the accident ______________________________________________________________________________________________________________________
Later that day ___________________________________________________________________________________________________________________________________
The next day ____________________________________________________________________________________________________________________________________
Please check your current symptoms:
Jaw / TMJ pain ( R / L )
Arm tingling / numbness ( R / L )
Radiating pain to hip / leg ( R / L )
Muscle spasms / soreness
Headache ( R / L )
Elbow pain ( R / L )
Hip / leg pain ( R / L )
Anxiety / depression
Neck pain ( R / L )
Wrist pain ( R / L )
Leg tingling / numbness ( R / L )
Dizziness / fainting
Mid back pain ( R / L )
Hand pain ( R / L )
Knee pain ( R / L )
Fatigue
Radiating pain to head ( R / L )
Hand tingling / numbness ( R / L )
Ankle pain ( R / L )
Ringing / buzzing in the ears
Radiating pain to shoulder / arm ( R / L )
Low back pain ( R / L )
Foot pain ( R / L )
Visual disturbances
Shoulder / arm pain ( R / L )
Sacroiliac pain ( R / L )
Foot tingling / numbness ( R / L )
Other ___________________________
List any other present complaints and symptoms ______________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
Before the accident did you have any of your present complaints?
Yes
No
If yes, describe __________________________________________________________________________________________________________________________________
Have you lost time from work as a result of this accident?
Yes
No
If yes, list dates lost ______________________________________________________
Type of employment _____________________________________________________
Insurance companies involved:
Insurance company of party responsible for payment ___________________________________________________________________________________________________
Claim # ____________________________
Phone _____________________________
Adjustor _______________________________________________________________
Your automobile insurance company ________________________________________________________________________________________________________________
Agent _____________________________
Phone _____________________________
Do you have Med-Pay coverage?
Yes
No
I'm not sure
Your group health insurance company _______________________________________________________________________________________________________________
Policy # ___________________________
Phone _____________________________
Have you retained an attorney?
Yes
No
If yes, who? _____________________________________________________________
Phone _____________________________
Assignment Of Benefits
By signing this form you authorize your insurance company to make payments directly to this clinic; however, you are ultimately responsible for payment. If your insurance
company sends checks to you, you are legally obligated to bring them to us.
____________________________________________________________________
___________________________________
Signature of patient or legal guardian
Date
____________________________________________________________________
Clinic Representative
BROWN CHIROPRACTIC/ACUPUNCTURE, PC
PO BOX 25465 TEMPE, AZ 85285-5465
480-377-1226
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