Accident And Injury Update Form printable pdf download

Accident and Injury Update

_____________________________________________________________

Patient Information

Thank you for choosing Goffstown Chiropractic Care, PLLC for your chiropractic needs. Please complete this form in ink. If you

have any questions or concerns, please do not hesitate to ask for assistance. We are happy to help.

(please print clearly)

Name: ___________________________________________________ Social security number: ______________________________

Address: _____________________________________ City: ______________________ State: _____ Zip code: ________________

Sex:  Female  Male

Date of birth: ____________________ E-mail: __________________________________________

Home phone: (______)__________________ Cell phone: (_____)__________________ Work phone: (_____)_________________

I prefer to receive appointment reminders via:  E-mail

 Cell phone text – my carrier is _______________________________

 Married

 Widow(er)

 Single

 Minor

 Separated

 Divorced

 Partnered for _____ years

Patient employer/school: _________________________________________ Occupation: __________________________________

Employer/school address: ________________________________ City: ___________________ State: _____ Zip code: __________

Spouse or parent’s name: ___________________________ Employer: ____________________ Work phone: (_____)___________

Person to contact in case of emergency: ______________________________________________ Phone: (_____)_______________

_______________________________________________________________

Responsible Party

Name of person responsible for this account: _____________________________ Social security number: _____________________

Relationship to patient: __________________________________________________________ Phone: (_____)_________________

Address: _____________________________________ City: ______________________ State: _____ Zip code: ________________

___________________________________________________________

Insurance Information

Insurance company name: _______________________________________________________ Phone: (_____)_________________

Name of insured person (if other than patient): ____________________________________ Their date of birth: _________________

 Self

 Spouse  Child

 Other

Relationship of insured to patient:

 Automobile

 Worker’s compensation

Insurance policy:

Claim number: ________________________________________ Date of accident or injury: ________________

Name of insurance case worker: ______________________________________ Phone: (_____)________________

 Automobile  Other ____________________

Accident/injury is related to: Employment

_____________________________________________________________________

Symptoms

Reason for visit: _____________________________________________

When did you first notice your symptoms? ________________________

How do you think your symptoms began? _________________________

___________________________________________________________

Indicate on the drawings to the right where you have pain/symptoms:

How often do you experience your symptoms?

 Constantly (76-100% of the time)  Frequently (51-75% of the time)

 Occasionally (26-50% of the time)  Infrequently (1-25% of the time)

How are your symptoms changing with time?

 Getting worse

 Staying the same

 Getting better

Accident And Injury Update Form

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