Personal Injury History Form (Non-Vehicular)
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1BAKKE CHIROPRACTIC CLINIC
PERSONAL INJURY HISTORY FORM (Non-Vehicular)
Name:__________________________________ DOB: ________________ Date:______________ Case#:___________
Time of accident:______________ AM
PM
Date of accident:______________________
Location of accident:___________________________________________________________________________________
Describe what happened (be specific):______________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Were you cut or bruised? Yes
No If yes, describe:____________________________________________________
Were you knocked unconscious? Yes
No
Was a police report done? Yes No
Did the rescue squad come to the accident? Yes No
Were you evaluated by them? Yes No
Describe specifically how you felt: IMMEDIATELY after the accident___________________________________________
____________________________________________________________________________________________________
later that day_________________________________________________________________________________________
the day after_________________________________________________________________________________________
List ALL medical doctors, doctors of chiropractic, and physical therapists you have seen since the accident: ______________
____________________________________________________________________________________________________
Are you currently on any work restrictions? Yes
No If yes, by whom?___________________________________
What are the restrictions?______________________________________________________________________________
Do you have an attorney? Yes No If yes, attorney name:_____________________________ Ph#________________
Before this accident, were you having symptoms in the areas of your body now affected? Yes
No
If yes, what? (be specific)______________________________________________________________________________
Before this accident, have you ever injured or had symptoms in the area of your body now affected? Yes
No
If yes, what and when? (be specific)______________________________________________________________________
Due to physical problems or symptoms, are your daily activities different since the accident? Yes
No
If yes, what are you unable to do now?____________________________________________________________________
If yes, what is now painful or difficult to do________________________________________________________________
RESPONSIBLE PARTY INFORMATION
Responsible Party Name:________________________________________________ Phone #______________________
Address:__________________________________________________________________________________________
_________________________________________________________________________________________________
Name of Insurance Company:____________________________________________ Phone #______________________
Address:__________________________________________________________________________________________
_________________________________________________________________________________________________
Policy #:_____________________________ Group #:_________________ Claim #___________________________
My signature below verifies that I have read, understood and truthfully answered each question to the best of my ability.
Patient’s Signature:________________________________________________
Date:___________________________
Form # PI-108 revised 03/21/11
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