blockchiropracticcenter.com - Accident Questionnaire

AUTOMOBILE ACCIDENT QUESTIONNAIRE
Patient's Name:
Today's Date:

MonthDayYear
Date
Date of Accident:

MonthDayYear
Date
THE FOLLOWING QUESTIONS PERTAIN TO YOU AND THE VEHICLE YOU WERE IN:
Vehicle Type

CarvanPickupTruckBusStation WagonOther
Vehicle Size

SubcompactCompactMid-sizeHeavyFull-sizeMiniLightOther
Your position in the vehicle

DriverPassengerOther
Location

LeftMiddleRightFront PassengerRear PassengerThird Seat (rear)
Speed of your vehicle

StoppedParkedSlowingMoving SlowlyMoving ModeratelyMoving FastMoving at approximately(MPH)
Why vehicle was slowed or stopped

Traffic SignalParkingTrafficStop SignBusy IntersectionPedestrian
Collision Type

Driver Side ImpactHead on collisionRear ImpactPedestrian IncidentFront ImpactPassenger Side Impact
THE FOLLOWING QUESTIONS CONCERN INVOLVED TO THE OTHER VEHICLE IN THE ACCIDENT
Vehicle Type

CarvanPickupTruckBusStation WagonOther
Vehicle Size

SubcompactCompactMid-sizeHeavyFull-sizeMiniLightOther
CONDITIONS AT THE TIME OF ACCIDENT
Time of day

Full daylightDuskNight
Road Conditions

DryDampWetSnow coveredIce coveredPatchy Ice/Snow
Visibility

ExcellentGoodFairPoor
Visibility compromised by

BrightnessDarknessRainSnowFogTraffic
THE FOLLOWING QUESTIONS CONCERN THE MOMENT OF IMPACT OF THE ACCIDENT:
Were you...

Totally unaware that the accident was impendingAware that the accident was impendingAware that the accident was impending and braced for it
Restraints: (check all that apply)

Seat beltShoulder harnessNo restraints
If you were the driver of the vehicle, was your foot on the brake pedal?

YesNoKnocked off by impact
Was the air bag deployed?

Car not equipped with air bagAir bag deployedAir bag not deployed
Was the air bag deployed?

High positionMiddle positionLow position
Position of YOUR head at time of impact?

Facing straight aheadTilted forwardRotated to the leftRotated to the right
Was your head thrown...?

Backward and then forwardForward then backwardTo the leftTo the rightTo the left then the rightTo the right, then the left
Position of your body at time of impact?

StraightTilted forwardRotated to the leftRotated to the right
Was your body thrown...?

Backward and then forwardForward then backwardTo the leftTo the rightTo the left then the rightTo the right, then the leftUnder the vehicleAcross the vehicleOutside the vehicle
Citations:

None issuedYourselfDriver of vehicle patient was a passenger ofDriver of other vehicleNot sure
AS A RESULT OF THE FORCE OF THE COLLISION, WHICH OBJECTS IN THE VEHICLE DID YOUR BODYSTRIKE?
Head

Steering wheelDashboardWindshieldArmrestHeadrestRear view mirrorLeft doorRight doorLeft windowRight windowConsoleGear shiftFront seatBackseat
Left Arm

Steering wheelDashboardWindshieldArmrestHeadrestRear view mirrorLeft doorRight doorLeft windowRight windowConsoleGear shiftFront seatBackseat
Right Arm

Steering wheelDashboardWindshieldArmrestHeadrestRear view mirrorLeft doorRight doorLeft windowRight windowConsoleGear shiftFront seatBackseat
Torso

Steering wheelDashboardWindshieldArmrestHeadrestRear view mirrorLeft doorRight doorLeft windowRight windowConsoleGear shiftFront seatBackseat
Left Leg

Steering wheelDashboardWindshieldArmrestHeadrestRear view mirrorLeft doorRight doorLeft windowRight windowConsoleGear shiftFront seatBackseat
Right Leg

Steering wheelDashboardWindshieldArmrestHeadrestRear view mirrorLeft doorRight doorLeft windowRight windowConsoleGear shiftFront seatBackseat
THE FOLLOWING QUESTIONS CONCERN THE TIME PERIOD IMMEDIATELY FOLLOWING THE ACCIDENT:
Did you lose consciousness?

YesNo
Were you able to walk unaided?

YesNo
Immediately following the accident, did you feel...?

DizzyDazedDisorientedWeakNervousNauseated
Where did you go...?

Drove homeWas driven homeDrove to hospitalwas driven to hospitalTaken to hospital via ambulanceDrove to workWas driven to workDrove to schoolWas driven to school
Next day discomfort...?

IncreasedDecreasedSame
Did your major complaints exist before the accident?

YesNo
In what areas did you IMMEDIATELY feel pain
HeadShoulderNeckUpper backMid backRibsChestAbdomenLow BackPelvis

	Left	Right
Shoulder
Arm
Elbow
Wrist
Hand
Fingers
Buttock
Hip
Thigh
Knee
Calf
Ankle
Foot
Toes

In what areas did you experience lacerations(cuts)?
HeadShoulderNeckUpper backMid backRibsChestAbdomenLow BackPelvis

	Left	Right
Shoulder
Arm
Elbow
Wrist
Hand
Fingers
Buttock
Hip
Thigh
Knee
Calf
Ankle
Foot
Toes

At the hospital, what areas were x-rayed ?
HeadShoulderNeckUpper backMid backRibsChestAbdomenLow BackPelvis

	Left	Right
Shoulder
Arm
Elbow
Wrist
Hand
Fingers
Buttock
Hip
Thigh
Knee
Calf
Ankle
Foot
Toes

Where did you experience pain on the day FOLLOWING the accident?
HeadShoulderNeckUpper backMid backRibsChestAbdomenLow BackPelvis

	Left	Right
Shoulder
Arm
Elbow
Wrist
Hand
Fingers
Buttock
Hip
Thigh
Knee
Calf
Ankle
Foot
Toes

AUTHORIZATION TO PAY PHYSICIAN
Patient:
Claim/Group #:
Date of Injury:

MonthDayYear
Date
I hereby instruct and direct the Insurance company to pay by check made out and mailed directly to:
Block Chiropractic and Rehabilitation Center, LLC

3901 National Drive, Suite 250

Burtonsville, MD 20866

For professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment.

or

If my current policy prohibits direct payment to doctor, then I hereby also instruct and direct you to make out the check to me and mail it as follows:

C/o Block Chiropractic and Rehabilitation Center, LLC

3901 National Drive, Suite 250

Burtonsville, MD 20866

A photocopy of this assignment shall be considered as effective and valid as the original.

I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.
Date

MonthDayYear
Date
Signature of claimant

Clear
Witness
Signature of claimant, if other than policy holder:

Clear

DOCTORS LIEN
To: Attorney
Phone Number
Please enter a valid phone number.
From: Block Chiropractic and Rehabilitation Center

3901, National Drive Suite 250

Burtonsville, MD 20866

Telephone: (301)-476-7575

Fax (301)-476-7730
Records

I authorize the above-named doctor/clinic to furnish to the above named attorney all information provided by or pertaining to me, including all records relating to the above-named doctor's/clinic examination, diagnosis, treatment, prognosis, etc.

Doctor's/Clinic's Lien

I authorize and direct the above-named attorney to withhold from any disability, medical, no-fault, health, accident, worker's compensation benefits, or any other benefits, insurance or reimbursement which may be payable to me or for my benefit arising from the condition for which I have been treated or received services, any amount as may be necessary to pay for such treatment or service, and to pay any amount which may be due and owing to the above-named doctor/clinic.

Responsibility for Payment

I agree that I am personally responsible for prompt payment to the above-named doctor/clinic of all amounts that may be due and owing for treatment or services rendered to me for my benefit, that payment shall not be contingent upon the payrnent upon the payment to me of any benefit, insurance or reimbursement by any other party, and that the lien and direction to pay contained in the preceding paragraph is solely as additional security to the above —named doctor/clinic.

Cost of Collection

I agree that if any amount due and owing to the above-named doctor/clinic for treatment or services performed for me is not paid when due, interest collection costs, including attorney fees, will be added to the amount due.

Waiver

I specifically waive any claim of privilege with respect to the disclosure by the above-named doctor/clinic to the above-named attorney of information provided by or pertaining to me, which I specifically authorize to be disclosed.
Date:

MonthDayYear
Date
Patient's Signature

Clear
Date of Injury/illness:

MonthDayYear
Date
Name:
Acknowledgement

The undersigned attorney acknowledges receipt of notice of lien of the above named doctor-clinic, and agrees to withhold from any payment of benefits, insurance or reimbursement, and make payment of any anount as may be due and owing to the above-named doctor/clinic for treatment or services of the Patient directly to the above-named doctor/clinic.
Date

MonthDayYear
Date
Attorney's Signature:

Clear
Attorney: Please date, sign, and retum a copy to the above named doctor/clinic in the attached reply envelope. Keep one copy for your records.

PERSONAL INJURY INSURANCE INFORMATION
What is the make and year of the vehicle you were in?
Name of the owner:
Driver:
Name of the insurance company of the above car
Address of Insurance Company
Phone Number of Insurance Company
Please enter a valid phone number.
Adjusters Name
Policy #
Claim #
What is the make and year of the vehicle that hit you?
Name of the owner:
Driver:
Name of the insurance company of the above car
Address of Insurance Company
Phone Number of Insurance Company
Please enter a valid phone number.
Adjusters Name
Policy #
Claim #
What is your attorney's name?
Their Address
Phone Number
Please enter a valid phone number.
Have you signed papers?
What is your health insurance company?
Policy #
Group #
SS #
Insurance Company Address
Phone Number of Insurance Company
Please enter a valid phone number.
Should be Empty:

	Date of Treatment	Name of Dr./Therapist	Purpose of Results
1
2
3

AUTOMOBILE ACCIDENT QUESTIONNAIRE

THE FOLLOWING QUESTIONS PERTAIN TO YOU AND THE VEHICLE YOU WERE IN:

THE FOLLOWING QUESTIONS CONCERN INVOLVED TO THE OTHER VEHICLE IN THE ACCIDENT

CONDITIONS AT THE TIME OF ACCIDENT

THE FOLLOWING QUESTIONS CONCERN THE MOMENT OF IMPACT OF THE ACCIDENT:

AS A RESULT OF THE FORCE OF THE COLLISION, WHICH OBJECTS IN THE VEHICLE DID YOUR BODYSTRIKE?

THE FOLLOWING QUESTIONS CONCERN THE TIME PERIOD IMMEDIATELY FOLLOWING THE ACCIDENT:

In what areas did you IMMEDIATELY feel pain

In what areas did you experience lacerations(cuts)?

At the hospital, what areas were x-rayed ?

Where did you experience pain on the day FOLLOWING the accident?

AUTHORIZATION TO PAY PHYSICIAN

DOCTORS LIEN

PERSONAL INJURY INSURANCE INFORMATION