Seattle Chiropractic and Wellness Group | Chiropractor in Seattle WA US

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Home
About Us
Services
New Patient Center
Success Stories
Therapies & Techniques
- Techniques
- Therapies
Blog
Community Content
Pay My Bill
Online Store

(206) 826-1005

Home

New Patient Auto Accident Form

New Patient Auto Accident Form

Name*

Email *

Phone *

Todays Date

Date of Accident

INFORMATION ABOUT THE MOTOR VEHICLE ACCIDENT:

City where accident occurred

Were you the

Were you struck from:

FRONT REAR LEFT SIDE RIGHT SIDE

Were you aware of the collision prior to impact or did it catch you by surprise?

AWARE UNAWARE

What position was your head facing during impact?

FORWARD LEFT RIGHT OTHER

If other, please state

Were you wearing a seatbelt with a shoulder harness?

YES NO LAP BELT ONLY UNKNOWN

Head Restraint:

NONE ADJUSTIBLE UP DOWN SEATBACK ONLY DON’T KNOW

Did Airbags Deploy?

Yes No

If YES, were you struck by Airbags?

Yes No

Road conditions were:

DRY WET ICY SNOW

Did the police show up to the scene?

Yes No

Who was at fault?

Driver of other vehicle Driver of my vehicle Myself Don’t Know

Please describe the accident (i.e., Rear‐ended, Side‐swiped, Head‐on etc.)

Did you receive any visible cuts or bruises as a result of the accident?

Yes No

If YES, Where?

Did you strike any parts of your body on the interior of the vehicle?

Yes No

If YES, Explain?

Following the collision, did you experience:

DIZZINESS NAUSEA CONFUSION/DISORIENTATION HEADACHES

Did your pain begin:

IMMEDIATELY HOURS LATER DAYS LATER OTHER

If other, please state

INFORMATION ABOUT THE VEHICLE YOU WERE IN:

Year

Maker

Model

What was the estimated speed of your vehicle during impact?

Was your vehicle:

SLOWING DOWN ACCELERATING STEADY SPEED STOPPED PARKED

Was you vehicle pushed forward after impact?

Yes No

If YES, How much?

Did your vehicle strike any other objects after the crash?

Estimated amount of damage to your vehicle?

Estimated damage to other vehicle?

NONE MINIMAL MODERATE MAJOR

INFORMATION ABOUT OTHER VEHICLE(S) INVOLVED IN ACCIDENT:

Year

Maker

Model

What was the estimated speed of the other vehicle during impact?

Was the other vehicle:

SLOWING DOWN ACCELERATING STEADY SPEED STOPPED PARKED

If more than one other vehicle was involved, please explain.

HOSPITAL EMERGENCY ROOM QUESTIONS:

Were you taken to a hospital/emergency room after the accident?

Yes No

DATE (If not same day)

Name of hospital/emergency room?

City

How did you get to the hospital/emergency room?

AMBULANCE YOURSELF SOMEONE ELSE DROVE YOU

Were X‐Rays Taken?

Yes No

If yes, were X‐Rays taken:

Laying down Standing Seated

Which areas of your body were X‐Rayed?

NECK MID BACK LOW BACK OTHER

If other, please state

Was any treatment administered at the hospital?

ICE HEAT CERVICAL COLLAR MEDICATION

FOLLOW UP INSTRUCTIONS:

OTHER HEALTH CARE PROVIDERS SEEN AFTER THE ACCIDENT:

Dr.

Specialty

Referred By

Date first seen

Treatment type

Treatment frequency/duration

Currently treating?

Yes No

Any disability?

Yes No

If YES, please describe

Special tests (X‐Rays, MRI, CT)

Did treatments help?

Yes No

Dr.

Specialty

Referred By

Date first seen

Treatment type

Treatment frequency/duration

Currently treating?

Yes No

Any disability?

Yes No

If YES, please describe

Special tests (X‐Rays, MRI, CT)

Did treatments help?

Yes No

QUESTIONS ABOUT YOUR WORK AND SOCIAL HISTORY:

What is your occupation?

Employer at time of injury?

Employers Phone #?

Employers Address

Is this accident an on the job injury?

Yes No

If YES, have you reported it to your employer?

Yes No

Has an on the job injury claim been filed?

Yes No

If YES, what is the claim number?

Have you lost time from work as a result of this injury?

Yes No

If YES, please list dates

Date you returned to work or expect to return to work

I am currently working:

FULL‐TIME PART‐TIME ___ HRS/WEEK REGULAR DUTY LIGHT‐DUTY