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Insurance & Payment for Care
I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.
Personal Health History
Health Problems & Concerns
Past Health History:
Family Health History
Please list diagnosed health conditions and untimely deaths.(condition, relationship to you)
(Family members include: Parents and siblings and maternal and paternal grandparents/aunts/uncles)
Social History & Life Choices:
Reason for this Visit
If you're only here for chiropractic wellness services please skip this section.
Automobile Crash Questionaire
1. Vehicle Type
2. Vehicle Size
3. What was Your location in vehicle?
4. Passenger Location?
5. What was the vehicle you were in doing?
6.What damage did the vehicle you were in sustain?
a. Vehicle Type
b. Vehicle Size
c. How did this vehicle strike the vehicle you were in?
d. What damage did this vehicle sustain?
a.What time of day did the accident occur?
Explanation (if needed)
b.What was the Condition of the road?
a.What was the visibility at impact?
b.If the visibility was Poor Why?
AT MOMENT OF IMPACT
1.Were you prepared for the accident?
a.Was your foot on brake pedal at impact?
b.Was it knocked off pedal by impact?
a.Were you wearing restraint belt?
b.What type of restraint belt were you wearing?
a.Was vehicle equipped with headrests?
b.What position was the headrest in?
a.Was vehicle equipped with airbags?
b.Did the airbag deploy?
a.What was your body position at impact?
b.What direction was your body thrown?
a.What was your head / neck position at impact?
b. What motion was your head / neck pitched?
Which object in the vehicle did the force of the collision cause your body to strike?
b.Right Upper Extremity (Arm)
c.Left Upper Extremity (Arm)
e.Right Lower Extremity (Leg)
f.Left Lower Extremity (Leg)
2.Did Your Body Strike Any Other Objects?
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