Supplemental History: Auto Accident Form (Page 2 of 2) in pdf

SUPPLEMENTAL HISTORY: AUTO ACCIDENT

Describe how you felt:

During the accident _______________________________________________________________________________________________________________________________

Immediately after the accident ______________________________________________________________________________________________________________________

Later that day ___________________________________________________________________________________________________________________________________

The next day ____________________________________________________________________________________________________________________________________

Please check your current symptoms:

Jaw / TMJ pain ( R / L )

Arm tingling / numbness ( R / L )

Radiating pain to hip / leg ( R / L )

Muscle spasms / soreness

Headache ( R / L )

Elbow pain ( R / L )

Hip / leg pain ( R / L )

Anxiety / depression

Neck pain ( R / L )

Wrist pain ( R / L )

Leg tingling / numbness ( R / L )

Dizziness / fainting

Mid back pain ( R / L )

Hand pain ( R / L )

Knee pain ( R / L )

Fatigue

Radiating pain to head ( R / L )

Hand tingling / numbness ( R / L )

Ankle pain ( R / L )

Ringing / buzzing in the ears

Radiating pain to shoulder / arm ( R / L )

Low back pain ( R / L )

Foot pain ( R / L )

Visual disturbances

Shoulder / arm pain ( R / L )

Sacroiliac pain ( R / L )

Foot tingling / numbness ( R / L )

Other ___________________________

List any other present complaints and symptoms ______________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________

Before the accident did you have any of your present complaints?

Yes

If yes, describe __________________________________________________________________________________________________________________________________

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

Yes

If yes, list dates lost ______________________________________________________

Type of employment _____________________________________________________

Insurance companies involved:

Insurance company of party responsible for payment ___________________________________________________________________________________________________

Claim # ____________________________

Phone _____________________________

Adjustor _______________________________________________________________

Your automobile insurance company ________________________________________________________________________________________________________________

Agent _____________________________

Phone _____________________________

Do you have Med-Pay coverage?

Yes

I'm not sure

Your group health insurance company _______________________________________________________________________________________________________________

Policy # ___________________________

Phone _____________________________

Have you retained an attorney?

Yes

If yes, who? _____________________________________________________________

Phone _____________________________

Assignment Of Benefits

By signing this form you authorize your insurance company to make payments directly to this clinic; however, you are ultimately responsible for payment. If your insurance

company sends checks to you, you are legally obligated to bring them to us.

____________________________________________________________________

___________________________________

Signature of patient or legal guardian

Date

____________________________________________________________________

Clinic Representative

BROWN CHIROPRACTIC/ACUPUNCTURE, PC

PO BOX 25465 TEMPE, AZ 85285-5465

480-377-1226