Elixia Motor Vehicle Accident Injury History Form Page 2
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1
2FOLLOWING THE ACCIDENT
How you felt immediately: ______________________
Later that day: ___________
How you felt the next day: _________________________________________________
Yes – Where? _________________
Did you go to urgent care/emergency?
No
Private car – whose? ______
How did you get there?
Ambulance
Treatment rendered: _____________________________________________________
Yes – Which body part(s)? ___________________
X-ray or MRI taken?
No
List the extent of your injuries as you know them: _______________________________
______________________________________________________________________
______________________________________________________________________
Yes – When? __________________
Has this/these part(s) been injured before? No
No – How long did you stay? ___________
Were you released the same day?
Yes
Recommendation/Home Care: _____________________________________________
Advice to see:
Medical Doctor
Physical Therapist
Chiropractor
Have you seen any other doctor as a result of this accident?
No
Yes
If yes, who? ____________________________________________________________
Diagnosis: _____________________________________________________________
Treatment: _____________________________________________________________
Yes – Dates: from ______ to ______
Have you lost any work because of this?
No
Yes – How many? ________
Have you been involved in any other accidents?
No
Please describe past injuries including dates, types, and treatment received: _________
______________________________________________________________________
______________________________________________________________________
Please check symptoms you have noticed since this accident:
_ Headache
_ Irritability
_ Hip pain
_ Numbness (arms)
_ Neck pain
_ Chest pain
_ Leg pain
_ Numbness (legs)
_ Stiff neck
_ Dizziness
_ Knee pain
_ Depression
_ Sleep problems
_ Shoulder pain
_ Ankle pain
_ Fatigue
_ Back pain
_ Arm pain
_ Foot pain
_ Lights bother eyes
_ Nervousness
_ Elbow pain
_ Pins & Needles(arms) _ Loss of balance
_ Loss of Memory
_ Wrist pain
_ Pins & Needles (legs) _ Fainting
_ Ears Ring
_ Hand pain
_ Shortness of breath
_ Loss of smell/taste
_ Diarrhea
_ Cold feet/hands
_ Upset stomach
_ Fever
_ Constipation
_ Other: ___________________________________________________
Is there any additional information you would like to provide re: this accident: _________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
The medical and accident information I’ve provided is true and accurate to the best of
my knowledge. I also acknowledge and agree to abide by the claims payment policies.
Patient Signature _____________________________________ Date____________
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