Creative Wellness Chiropractic
Personal Injury/Auto Accident Intake

Personal Injury/Auto Accident Intake

Auto Accident Intake Form

This form is to be filled out in completion if you were in an accident or had a personal injury claim.

Personal Injury/Auto Accident Intake

Name(Required)
MM slash DD slash YYYY
Address(Required)

Medical History

Please indicate any significant condition that you have experienced.(Required)

Accident Description

MM slash DD slash YYYY
Time of Accident(Required)
:
Were you the:(Required)
Any Bruises?(Required)
Did the airbag deploy?(Required)
Did any part of your body strike part of the vehicle?(Required)
Explain your symptoms/complaints
At the time of impact were you:(Required)
Was a police report filed?

After the accident

Were you hospitalized?(Required)
If yes, what type?
List any medications you are currently taking.(Required)
If none, put N/A.
If none, put N/A.
If none, put N/A.
Have you had any of the following previously? Mark all that apply.(Required)

Vehicle Information

Patient's Auto Insurance Info:

Other Vehicle's Auto Insurance

Patient's Health Insurance

Attorney's Info

Acknowledgment and Agreement(Required)
Name (Print & Sign)(Required)
MM slash DD slash YYYY