--- title: "Personal Injury/Auto Accident Intake" url: "https://yourchiropractorinsandiego.com/personal-injury-auto-accident-intake/" post_type: "page" date_published: "2023-08-23T05:11:24-07:00" date_modified: "2023-08-23T05:11:25-07:00" --- # 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) First Last Date of Birth(Required) MM slash DD slash YYYY Email(Required) Cell Phone(Required) Work Phone Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employer/School Occupation Emergency Contact Emergency Contact Phone Number Medical History Please indicate any significant condition that you have experienced.(Required) Insomnia Fatigue Depression Anxiety Headaches Stiff Neck Dizziness Blurred Vision TMJ Heart Disease Pacemaker Rheumatoid Arthritis Osteoarthritis Prosthetic Device Diabetes Multiple Sclerosis Joint Pain Sore Muscles Weak Muscles Difficulty Walking Neck/Shoulder Pain Upper Back Pain Low Back Pain Rib Pain Limited Range of Motion Plantar Fascitis Herniated Disc Osteoporosis Fractures Seizures Metal Pins Stroke Poor Coordination Parkinson’s Disease Cancer Tremors Numbness or Tingling Pinched Nerve Paralysis Select All Are you currently pregnant? If so, how many weeks?(Required) Accident Description Date of Accident(Required) MM slash DD slash YYYY Time of Accident(Required) Hours : Minutes AMPM AM/PM Were you the:(Required) Driver Front Passenger Rear Passenger Pedestrian Any Bruises?(Required) Yes No Did the airbag deploy?(Required) Yes No Did any part of your body strike part of the vehicle?(Required) Yes No Your condition immediately following the accident:(Required) Explain your symptoms/complaints At the time of impact were you:(Required) surprised by impact bracing for impact looking straight ahead looking up looking down looking to the right looking to the left looking in the mirror Which hand was on the wheel?(Required) RightLeftBothNeither Which foot was on the brake?(Required) RightLeftBothNeither Please describe the accident in your own words:(Required) To the best of your knowledge, describe what happened to your body at the time of impact.(Required) Location of the accident:(Required) Speed you were traveling:(Required) Driving Conditions:(Required) DarkDryWet/SlipperyFoggyDirt/GravelOther Was the impact from:(Required) FrontFront rightFront leftRear rightRear leftLeft sideRight side What was the position of the headrest compared to your head(Required) LowMiddleHighNone Were you wearing a seatbelt?(Required) YesNo Were the police there?(Required) YesNo Was a police report filed? After the accident Were you hospitalized?(Required) Yes No If yes, what type? Self Transport Ambulance Were X-Rays taken? If so, which areas?(Required) Number of people in the car?(Required) 12345 Did you see your primary care or seek other treatment before coming here, if yes explain.(Required) List any medications you are currently taking.(Required) Add Remove If none, put N/A. Have you missed work due the accident? If yes how many?(Required) If none, put N/A. History of neck pain or headaches?(Required) YesNo TMJ dysfunction (Pre-existing or developing due to the accident)(Required) YesNo Prior trauma or injury to the area of complaint before this accident? If yes, explain.(Required) If none, put N/A. Have you had any of the following previously? Mark all that apply.(Required) Spinal Injuries Sleep disturbances Stress Recent history of depression Select All Vehicle Information Your vehicle year:(Required) Your vehicle make:(Required) Your vehicle model:(Required) Amount of damage to your vehicle $(Required) Their vehicle year:(Required) Their vehicle make:(Required) Their vehicle model:(Required) Amount of damage to their vehicle $(Required) Patient's Auto Insurance Info: Insurance Company(Required) Phone Number(Required) Policy Number(Required) Claim Number(Required) Medical Payments Coverage? If yes, what amount?(Required) Other Vehicle's Auto Insurance Name on Policy(Required) Insurance Company(Required) Phone Number(Required) Policy Number(Required) Claim Number(Required) Claim Adjuster Name/Phone if known?(Required) Patient's Health Insurance Name on Policy(Required) Insurance Company(Required) Policy Number(Required) Phone Number(Required) Attorney's Info Attorney's Name and Company Name:(Required) Attorney's Phone Number:(Required) Acknowledgment and Agreement(Required) I agree to the following information stated above. We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient. I certify to the best of my knowledge the above information is complete and accurate. If the health plan information is not accurate, or if I am not eligible to receive a health care benefit through this provider, I understand that I am liable for all charges for services rendered and I agree to notify this doctor immediately whenever I have changes in my health condition or health plan coverage. Name (Print & Sign)(Required) Print E-Signature Today's Date(Required) MM slash DD slash YYYY Δ