Accident And Injury Update Form (Page 2 of 2) in pdf

____________________________________________________________

Symptoms, continued

 Sharp

 Dull

 Throbbing  Numbness  Achiness

 Shooting 

Type of pain:



 Burning

 Tingling  Cramps

 Stiffness

 Swelling

 Other: ___________________

Rate the severity of your pain. (1 = mild pain or discomfort, to 10 = severe pain)

1 2 3 4 5 6 7 8 9 10

What aggravates your condition? _________________________________________________________________________________

What makes your condition better? _______________________________________________________________________________

What treatment have you received for your condition?

 Medication

 Surgery

 Chiropractic

 Physical therapy  Massage

 None

 Other ___________________

How much has your condition interfered with your work and social activities?

 Not at all

 A little bit  Moderately

 Quite a bit

 Extremely

Do you consider your condition to be severe?  Yes

 Yes, at times  No

What concerns you the most about your condition? What does it prevent you from doing? __________________________________

__________________________________________________

Motor Vehicle Accident

(if applicable)

Date of accident: ___________________________

Time of accident: _______________________________

How and where did the accident happen? _________________________________________________________________________

Where were you sitting at the time of the accident? _________________________________________________________________

Please mark the following that apply at the time of the accident:

 Wearing seat belt

 Air bag deployed

 Body hit interior of car

 Ejected from vehicle

 Lost consciousness

 Unaware of impending collision  Aware of impending collision and relaxed  Aware of impending collision and tightened up

What happened after the accident?

 Police arrived

 Ambulance arrived

 Taken by ambulance to hospital

 Police report written

 Refused treatment

 Drove to hospital

 Went to doctor’s office

 Other: _______________________

Immediately after the accident, where did you feel pain/symptoms? ____________________________________________________

Currently where do you feel pain/symptoms? ______________________________________________________________________

Other treatment received for this accident: ________________________________________________________________________

____________________________________________

Worker’s Compensation Injury

(if applicable)

Date of injury: ___________________________

Time of injury: _______________________________

How and where did the injury happen? ___________________________________________________________________________

What happened after the injury?

 Continued working

 Stopped working

 Notified supervisor

 Incident report written

 Drove to hospital

 Went to doctor’s office

 Received no treatment

 Other: ___________________________

Immediately after the injury, where did you feel pain/symptoms? ______________________________________________________

Currently where do you feel pain/symptoms? ______________________________________________________________________

Are you currently working?  Yes, without restrictions

 Yes, with restrictions

 No

Other treatment received for this injury: __________________________________________________________________________

_______________________________________________________

Patient Payment Agreement

Our policy requires payment in full for all services rendered at the time of your visit, unless other arrangements have been made with

the doctor. I understand the above information and guarantee this form was completed correctly and to the best of my knowledge, and

I understand it is my responsibility to inform this office of any changes to my health record.

Signature ________________________________________________________ Date ________________________________

Accident And Injury Update Form Page 2

Related Articles

Related forms

Related Categories