Medical History Intake Form printable pdf download

Personal Injury / Accident

Medical History Intake Form

Release Chiropractic and Wellness Center

Please provide your Driver’s License to our staff for your file.

ABOUT YOU

Full Name: __________________________________________ Gender

F Age:_______ Birth Date: _____/_____/_____

Address: ___________________________________________ City: ____________________

State: ______ Zip: ___________

Social Security#: ______-_____-______ Driver’s License #: _________________________ Home Phone: (____) ______________

Spouse’s Name: ______________________ Referred by: ____________________________ Cell Phone: (____) ______________

Employer: _______________________ Occupation: ________________________________ Work Phone: (____) ______________

Employer Address: ____________________________________ City: ______________________ State:______ Zip: ____________

INSURANCE/ATTORNEY INFORMATION

Insurance Company of the Person at Fault: _____________________________________ Name of Agent: ______________________

Insurance Company Address: ______________________________ City: __________________

State: ______ Zip: ___________

Insurance Company Phone #: _________________________________ Agent’s Phone #: ___________________________________

Claim Number: _______________________________________________________

Have you retained an attorney?

Yes

Your Attorney’s Name:__________________________________

Your Attorney’s Phone: _________________________________

Your Attorney’s Address: _________________________________ City: ___________________

State: ______ Zip: __________

ACCIDENT INFORMATION

Date of Accident: ______/______/______

Time of Accident: ____________

a.m.

p.m.

Your Vehicle: Year ____________ Make _______________ Model ________________________ Your Speed ___________________

Other Vehicle: Year ___________ Make _______________ Model ________________________ Other Vehicle Speed ____________

Accident Type:

Rear ended

Head-on

Broad-sided

Damage to Your Vehicle: $_______ Other Vehicle Damage: $ ______

Describe the Accident:

___________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537

Medical History Intake Form