"Personal Injury Intake Form"

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Personal Injury Intake Form
It is necessary that if your injuries are due to an automobile accident that we are given the following information within
your first 2 visits or you may become responsible for continued charges. It is necessary to complete the following forms
to best of your ability. Detail is imperative.
Insurance Name: _____________________________ Phone Number:___________________________
Claim Address:__________________________________________________________________
Claim Number:__________________________ Adjuster Name:__________________________
Patient Name:__________________________________________ Date of Accident: _____________________
Time:__________
Where did the accident happen?_______________________________________________________________________
Describe the accident in your own words:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What was your position in the car?  Driver  Passenger
If passenger, were you sitting in  Front  Right Rear  Left Rear
Did your vehicle strike other vehicle?  Yes  No
Was your car struck by other vehicle?  Yes  No
Was the impact from:  the front  from the right side  from the left side  from the rear
At the time of impact were you:  looking straight ahead  looking right  looking left
Were both hands on the steering wheel?  Yes  No
Was your foot on the brake?  Yes  No
Were you braced for impact?  Yes  No
Where in the car were you after the accident? __________________________________________________________
Were you wearing seat belts?  Yes  No
Did you strike anything in the vehicle at the time of impact?  Yes  No
Please state part of body:  Chest  Chin  Knee  Shoulder  Hand  Head
Immediately following the accident how did you feel? ____________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Were you unconscious?  Yes  No
In a daze?  Yes  No
Did you go to the hospital?  Yes  No
How did you get to the hospital?  Ambulance  Private Transportation
Did the ambulance attendants place you in: Neck Collar  Yes  No
Splints  Yes  No Brace  Yes  No
Name of Hospital: _____________________________________________________________________________
Attended by Dr.________________________________________
Were you x-rayed at the hospital?  Yes  No
If Yes, what was the diagnosis? ________________________________________________________________________
Personal Injury Intake Form
It is necessary that if your injuries are due to an automobile accident that we are given the following information within
your first 2 visits or you may become responsible for continued charges. It is necessary to complete the following forms
to best of your ability. Detail is imperative.
Insurance Name: _____________________________ Phone Number:___________________________
Claim Address:__________________________________________________________________
Claim Number:__________________________ Adjuster Name:__________________________
Patient Name:__________________________________________ Date of Accident: _____________________
Time:__________
Where did the accident happen?_______________________________________________________________________
Describe the accident in your own words:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What was your position in the car?  Driver  Passenger
If passenger, were you sitting in  Front  Right Rear  Left Rear
Did your vehicle strike other vehicle?  Yes  No
Was your car struck by other vehicle?  Yes  No
Was the impact from:  the front  from the right side  from the left side  from the rear
At the time of impact were you:  looking straight ahead  looking right  looking left
Were both hands on the steering wheel?  Yes  No
Was your foot on the brake?  Yes  No
Were you braced for impact?  Yes  No
Where in the car were you after the accident? __________________________________________________________
Were you wearing seat belts?  Yes  No
Did you strike anything in the vehicle at the time of impact?  Yes  No
Please state part of body:  Chest  Chin  Knee  Shoulder  Hand  Head
Immediately following the accident how did you feel? ____________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Were you unconscious?  Yes  No
In a daze?  Yes  No
Did you go to the hospital?  Yes  No
How did you get to the hospital?  Ambulance  Private Transportation
Did the ambulance attendants place you in: Neck Collar  Yes  No
Splints  Yes  No Brace  Yes  No
Name of Hospital: _____________________________________________________________________________
Attended by Dr.________________________________________
Were you x-rayed at the hospital?  Yes  No
If Yes, what was the diagnosis? ________________________________________________________________________
Were you admitted to the hospital?  Yes  No
How long did you stay? ______________________________
What treatment was rendered?______________________________________________________________________
________________________________________________________________________________________________
What recommendations were made? See own doctor?  Yes  No
See orthopedic doctor?  Yes  No
Physical Therapy?  Yes  No
Have you seen any other doctor as a result of this accident?  Yes  No
Doctor’s Name: _______________________________________________________________________________
Is your pain constant?  Yes  No
Is the pain on and off?  Yes  No
Sharp?  Yes  No
Dull?  Yes  No
Other: __________________________________________________________________________________________
Is your pain worse when arising from a chair?  Yes  No
Is it made worse by straining?  Yes  No
By coughing?  Yes  No
By sneezing?  Yes  No
By straining when moving your bowels?  Yes  No
Do you have any numbness or tingling in your arms?  Yes  No
In your hands?  Yes  No
In your fingers?  Yes  No
In your legs?  Yes  No
In your feet?  Yes  No
In your toes?  Yes  No
What is your most comfortable position? Sitting  Yes  No Lying on your right side  Yes  No
Lying on your left side  Yes  No Lying on your back  Yes  No On your stomach  Yes  No
Standing  Yes  No
Other______________________________________________________
Is it difficult for you to move around in bed?  Yes  No
Does stretching and twisting worsen the pain?  Yes  No
Do any of the following relieve your pain?  Heating pad  Hot Bath  Shower  Ice pack
Does a brace (if you have tried one) help relieve the pain?  Yes  No
Does a change in heel height worsen the pain?  Yes  No
Do you feel better moving around?  Yes  No Or resting?  Yes  No
Do you have a firm mattress?  Yes  No
Do your knees ache or hurt?  Yes  No
Do you have cramps in your leg?  Yes  No In arm?  Yes  No
Have you had any change in your bowel habits?  Yes  No
Have you lots any time from work because of this accident?  Yes  No
If yes, give dates of time lost: From: _____________________ To:____________________________
Totally disabled from__________ to ____________ Partially disabled from _______________ to __________________
Before Your Accident, estimate your total lifting effort ability:
1. How much weight?  Maximum  Average
2. How far could you carry this weight? __________________ For how long a period of time? ______________
3. Was this lifting done at work?  Yes  No
Or at home or elsewhere?  Yes  No
4. How often did you carry this amount of weight? ___________________________________________
After Your Accident, describe your total lifting ability:
1. How much weight can you now lift without experiencing pain, discomfort, or restriction of motion?
_________________________________________________________________________________
2. Did you experience this paint, discomfort or restriction of motion before your accident?  Yes  No
3. How far can you carry this weight now? __________________ And for how long a period of time? __________
4. How often can you carry this weight? _____________________________________________________
5. Are you now limited in your lifting ability in some body position that you were previously not?  Yes  No
If so, specify position______________________________________________________________________
6. What symptoms does lifting produce? ________________________________________________________
7. How long do these symptoms last? ___________________________________________________________
Are you presently able to:
Lift:  Very Heavy _____lbs
 Heavy ______lbs
 Light______lbs
 Sitting _____ lbs
Work:  Very Heavy _____lbs
 Heavy ______lbs
 Light______lbs
 Sitting _____ lbs
What positions can you work in with a minimum demand of physical effort?
With minimum demand of physical effort, what positions can you work in part-time and for how long?
 Standing  Walking  Sitting
With minimum demand of physical effort, can work in a sitting position with some degree of walking or standing
activity?  Yes  No
Do you feel that you cannot perform any physical work activity?  Yes  No
Do you feel that you cannot perform any mental work?  Yes  No
Relate your before injury capacity ( mark ‘B’) and your After injury capacity (mark ‘A’) for performing activities:
1. Walking
Normal _____ Limited ______ Difficult ______ Pain ______
2. Standing
Normal _____ Limited ______ Difficult ______ Pain ______
3. Sitting
Normal _____ Limited ______ Difficult ______ Pain ______
4. Bending
Normal _____ Limited ______ Difficult ______ Pain ______
5. Stooping
Normal _____ Limited ______ Difficult ______ Pain ______
6. Lifting
Normal _____ Limited ______ Difficult ______ Pain ______
7. Pushing
Normal _____ Limited ______ Difficult ______ Pain ______
8. Pulling
Normal _____ Limited ______ Difficult ______ Pain ______
9. Climbing
Normal _____ Limited ______ Difficult ______ Pain ______
10. Reaching
Normal _____ Limited ______ Difficult ______ Pain ______
11. Gripping
Normal _____ Limited ______ Difficult ______ Pain ______
12. Kneeling
Normal _____ Limited ______ Difficult ______ Pain ______
13. Balance
Normal _____ Limited ______ Difficult ______ Pain ______
14. Fatigue
Normal _____ Limited ______ Difficult ______ Pain ______
Generally speaking, is your inability to perform these functions due to  Pain  Weakness  Structural limitations
 Nerves ?
Are you able to take care of your personal self, such as dressing, bathing, etc?  Yes  No or do you require
assistance?  Yes  No
Do you feel your present condition is temporary?  Yes  No or permanent?  Yes  No
Vehicles Involved:
Your Vehicle – Year ______ Make____________ Model _____________________
Other Vehicle – Year ________ Make ___________ Model____________________
Accident Type:  Rear ended  Head-on  Broad-sided Your Speed_____________ Other Vehicle Speed ________
Damage to Your Vehicle: $___________________
Other Vehicle Damage:$____________________
Air bag deployed?  Yes  No
The Road was:  Dry  Wet  Icy  Snowy
The Weather Conditions were:  Sunny  Cloudy  Foggy  Light Rain  Heavy Rain  Snowing
Time of Day:  Dawn  Day  Dusk  Night  Unknown
Other Doctors Seen:  Orthopedist  Psychiatrist  Massage Therapist  Neurologist
 Physical Therapy  Chiropractor
Any other information you would like to share with us:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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