Personal Injury Intake Form

Personal Injury Intake New Patient

Please complete this form prior at least 24 hours prior to your appointment. If you have a police report from your accident you can leave the accident details blank.
Personal Information
Name *

First Name Last Name
If your preferred name is different than your given name, please enter below:
Please enter your date of birth *

Month Day Year
Please enter your social security number - **please note**we are unable to set up any type of payment plan without a social security number *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email *
example@example.com
Phone Number *

Area Code Phone Number
Who referred you to our office? *

a friend my doctor Google/internet search my health insurance
If referred by friend, family or your physician, please provide their name:
Please provide a contact in case of emergency *

First Name Last Name
Emergency contact phone number *

Area Code Phone Number
Please enter the date of your accident: *

Month Day Year
Date
Is this accident work related?

yes no
Were the police called to the accident? *

Yes, and an accident report is available. No
Which seat did you occupy in the vehicle at the time of impact? *

driver passenger rear
Were you wearing a seatbelt? *

Yes No
Did the airbag deploy? *

Yes No
Which statement describes your knowledge of the accident?

I was completely surprised and did not see it coming I saw it coming
Please describe, to the best of your knowledge, what happened during the accident. *
Please select most appropriate statement below regarding your medical treatment after the accident. *

I was treated immediately afterwards at an Urgent Care or Emergency Department I did not seek medical treatment immediately afterwards
What treatment have you received after Urgent Care / Emergency Room *

Chiropractic care Physical therapy Primary care follow up no treatment received
Auto Insurance Information

Please complete this section entirely. If you are using health insurance or self-pay please skip this section.
Who was the driver of the automobile you were in? *

First Name Last Name
Please choose which option best applies *

I am the responsible party in the accident The other party was the responsible party in the accident Someone else was responsible, but we will be filing my auto insurance
Name of the auto insurance carrier *
Policy number
Claim number *
Who is the claim adjuster?

First Name Last Name
Claim adjuster phone number

Area Code Phone Number
If possible, please attach a picture of the front of your auto insurance card

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Who is the driver of the other vehicle?

First Name Last Name
Name of the other party's auto insurance carrier *
Other party's Policy number
Other party's Claim number *
Who is the other party's claim adjuster? *

First Name Last Name
Other party's Claim adjuster's phone number *

Area Code Phone Number
If possible, please attach a picture of the front of the other party's auto insurance card

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Attorney information

If you have retained an attorney to represent you in this case, please enter their information below. If not, please skip this step.
Attorney name

First Name Last Name
Attorney phone number

Area Code Phone Number
If at any point during or after your treatment you retain an attorney regarding this automobile accident, please be sure to notify us and provide us with their contact information. Please initial to acknowledge that you understand this statement. *
Health insurance policy information

Your auto insurance or the responsible party's auto insurance may cover your health care costs. If you would like us to bill the auto insurance carrier(s) for your treatment please be sure we have all necessary policy information.
Please select the name of your health insurance provider *

Auto insurance carrier is responsible, do not bill my health insurance Blue Cross Blue Shield Cigna Medcost United Healthcare Aetna Medicare
Subscriber ID / Member ID
This is generally listed on the front of your insurance ID card and may be alpha numeric. Please include all characters listed including any listed suffix (01,02,03, etc)
Group number
Please list your relationship to the insured

I am the policy holder My spouse is the policy holder I am a dependent of the policy holder No insurance/ Cash patient
Provider services phone number (usually listed on the back of the ID card)

Area Code Phone Number
If you are not the policy holder, please enter the policy holder's name

First Name Last Name
Policy holder's date of birth (mm/dd/yyyy)

Month Day Year
Date
If possible, please attach a picture of the front of your insurance card

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If possible, please attach a picture of the back of your insurance card

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Current condition information

Please use the following fields to describe what brings you into our office today.
*

I am seeking pain relief from a condition I had prior to this accident. I am seeking pain relief from a condition I now have as a result of this accident.
Please list your health concern(s) *
Please use the drawing tool to circle your area of complaint (s)
Please rate your pain on a scale of 0-10, 10 being the worst. *
The quality of my pain listed above is characterized as *

burning stabbing dull/ache stiff pins and needles / tingling
This pain is *

constant on and off
Does this pain radiate/shoot to other areas of the body? *

yes no
If it radiates, to which area does your pain travel?
If you answered yes the the last question (your pain radiates), please select which areas are affected

shoulder / arm / hands / fingers buttocks / leg ankle / foot right left both right and left
Please list all things which make your pain better *

ice heat rest movement / position change sitting standing stretching Rx medication OTC medication
Please list all the things which make your pain worse *

sitting standing movement / position change walking lying down sleeping heat

Please indicate how your condition impacts the following activities of daily living *

painful

some pain

not affected

bending

lifting

stairs

sitting

standing

walking

exercising

housework

kneeling

Please list any other providers who have treated this condition *

my primary care physician orthopedic doctor massage therapist physical therapist another chiropractor
Please list any imaging you have had in the last three months *

spinal xray spinal MRI
Lifestyle history

Please complete the following fields to the best of your ability. This information will help us with your case and should not be left blank.
Please list any supplements and over the counter medications you currently take *
Please list any prescription medications you are currently taking *
Do you use tobacco products?

No Yes Occasionally
Which statement best describes your exercise habits

I exercise regularly and frequently (3+ times per week on a regular basis) I exercise regularly but in-frequently (1-2 times per week on regular basis) I exercise every once in a while I don't exercise
How often to you consume alcoholic drinks?

rarely / never 1-3 drinks per week 3-5 drinks per week over 6 drinks per week
Which statement best describes your eating habits?

I eat fast food regularly (3+ times per week) I eat out sometimes and make healthy choices I eat clean (organic, whole foods most of the time)
Health history

Please fill out the following information to the best of your ability.
General: *

recent unintentional weight loss fever extreme fatigue none in this category
Musculoskeletal *

broken bones previous surgery (please explain in next section) none in this category
Neurological *

numbness or tingling sensations loss of feeling dizziness or lightheaded frequent or recurrent headaches head injury / concussion none in this category
Gastrointestinal *

loss of apetite bloody stool constipation diarrhea nausea or vomitting regular abdominal pain / bloating none in this category
Cardiovascular / heart *

chest pain rapid or heartbeat changes blood pressure regulation problems high cholesterol swelling of ankles and feet none in this category
Respiratory *

difficulty breathing persistent cough asthma coughing blood none in this category
Eyes / vision *

blurred or double vision eye disease or injury wear glasses / contacts none in this category
Genitourinary *

kidney stones burning / painful urination frequent urination urinary leakage / bed wetting blood in urine none in this category
Endocrine, hematologic, lymphatic *

thyroid problems diabetes cold hands / feet immune system disorder none in this category
Skin and breasts *

rash / itching non-healing sores breast pain breast lump none in this section
For women only: Are you pregnant?

yes no it's possible
If yes, what is your estimated date of delivery?

Month Day Year
Date
Do you have an immediate family history of any of the following? (check all that apply) *

cancer heart disease stroke no familial history of any of these conditions
Please list any surgeries in the field below. List surgery type and year performed.
Please sign below to indicate you have reviewed and understand the information above. *

Clear
HIPAA Privacy Practices Below
I have reviewed the HIPAA Privacy Practices for Gard Wellness Center (above) *

Clear
You're done! Thank you for completing this form, click 'Submit' below and we'll receive your information. We look forward to helping you life life well!
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Personal Injury Intake New Patient

Personal Information

Auto Insurance Information

Attorney information

Health insurance policy information

Current condition information

Lifestyle history

Health history