Medical History Intake Form Page 2
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8ACCIDENT SPECIFICS (Mark each that applies to the accident):
Job or work related injury
Yes
No
Were you the
Driver
Passenger
If the passenger, were you
Front seat
Back seat
Were you wearing your seatbelt?
Yes
No
Impending collision, were you
Aware
Unaware
Braced
Not braced
Did your head…
Strike object
Not strike object
Break glass
Did you experience…
Shock
Loss of consciousness
Flash of light seen upon impact
Did the airbag deploy?
Yes
No
IMMEDIATELY FOLLOWING THE ACCIDENT:
OTHER DOCTORS SEEN:
Ambulance / Paramedics were called
Orthopedist
I was treated at scene
Psychiatrist
Transported to hospital by ambulance
Massage Therapist
I went to Hospital on my own
Neurologist
I was diagnosed at the Hospital
Physical Therapist
I was treated at the Hospital
Chiropractor
Medication was prescribed
Other
Follow-up was recommended
THE ROAD WAS:
TIME OF DAY:
THE WEATHER WAS:
Dry
Dawn
Dry
Wet
Day
Sunny
Icy
Dusk
Rainy
Snowy
Night
Snowy
Cloudy
Foggy
State your Emotions and Physical State immediately following the accident: _______________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
State your Emotions & Physical State after the first few days: __________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537
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