Bakke Chiropractic Clinic Moving Vehicle Injury History Form printable pdf download

BAKKE CHIROPRACTIC CLINIC

MOVING VEHICLE INJURY HISTORY FORM (Vehicular)

Name:_________________________________ DOB: ________________ Date:______________ Case#:___________

 AM

 PM

Date of accident:______________________________

Time of accident:______________________

Were you the:  driver  front seat passenger

Driver of vehicle (if not you):______________________________

 rear seat passenger

Owner of vehicle:_______________________________________

Part of your vehicle involved:  front  rear

 driver side

 passenger side

 rolled

Road conditions:  icy  snowy  rainy  wet

 clear/dry

 Did you see the accident coming?  Yes  No

 Did you brace for impact?  Yes  No

Approx. speed of your vehicle:____ mph. Speed of other vehicle:____ mph.

Were your brakes applied?  Yes  No  Unsure  Were you wearing your seat belt/shoulder harness?  Yes  No

Position of your headrest at the time of the accident, even with?  your neck  lower half of head  upper half of head

Head position at time of impact:  turned right  turned left  looking up  looking down  looking forward

Body position at time of impact:  neutral  turned right  turned left

 Were you cut or bruised?  Yes  No

Did any part of your body hit anything inside the car?  Yes  No  Were you knocked unconscious?  Yes  No

Was a police report done? Yes  No  Did the rescue squad come? Yes  No  Were you evaluated? Yes  No

Describe what happened to you upon impact: ______________________________________________________________

___________________________________________________________________________________________________

Describe how you felt: immediately after the accident________________________________________________________

later that day_______________________________________________________________________________________

the day after_______________________________________________________________________________________

Before this accident, did you have symptoms in areas of your body now affected?  Yes  No

If yes, explain: ______________________________________________________________________________________

Are your daily activities different since the accident?  Yes  No If yes, explain: _______________________________

What is painful or difficult to do now ____________________________________________________________________

List ALL medical doctors, doctors of chiropractic, and physical therapists you have seen since the accident: ____________

_______________________________________________________________  Do you have an attorney?  Yes  No

Are you currently on any work restrictions?  Yes  No If yes, by whom?__________________________________

What are the restrictions?______________________________________________________________________________

AUTOMOBILE INSURANCE INFORMATION

Policy Holder Name ________________________________________________________________ Phone #__________________

Auto Insurance Name _______________________________________________ Phone # _________________________________

Address ____________________________________________________________________________________________________

Claim # ________________________________________ ID# /Group / Policy #_________________________________________

Adjuster’s Name:____________________________________________________ Phone #_________________________________

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# CA-107 revised 03/21/11

Bakke Chiropractic Clinic Moving Vehicle Injury History Form

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