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housemed@mikado.com
34th Avenue New York, W2 3XE

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Auto Accident Injury Intake Form

Automobile Accident Questionnaire

Patient's Name:
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Date of Accident:
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Today's Date:
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The following questions pertain to you and the vechile you were in:

Vehicle Type:
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Vehicle Size:
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Your position in the vehicle:
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Speed of your vehicle:
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Why Vehicle was slowed or stopped:
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Collision Type:
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The following questions concern the other vehicle involved in the accident:

Vehicle Type:
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Vehicle Size:
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CONDITIONS AT THE TIME OF THE ACCIDENT:

Time of day:
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Road Conditions:
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Visibility:
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Visibility compromised by:
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THE FOLLOWING QUESTIONS CONCERN THE MOMENT OF IMPACT OF THE ACCIDENT:

Were you...
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Restraints: (check all that apply)
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If you were the driver of the vehicle, was your foot on the brake pedal?
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Was the air bag deployed?
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What position was YOUR headrest in?
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Position of YOUR head at time of impact?
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Was your head thrown...?
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Position of Your body at time of impact?
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Was your body thrown...?
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Damage to vehicle YOU were in:
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Citations:
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AS A RESULT OF THE FORCE OF THE COLLISION, WHICH OBJECTS IN THE VEHICLE DID YOUR BODY STRIKE?

Head
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Left Arm
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Right Arm
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Torso
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Left Leg
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Right Leg
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THE FOLLOWING QUESTIONS CONCERN THE TIME PERIOD IMMEDIATELY FOLLOWING THE ACCIDENT:

Did you lose consciousness?
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Immediately following the accident, did you feel...?
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Were you able to walk unaided?
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Where did you go...?
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Next day discomfort...?
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Did your major complaints exist before the accident?
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In what areas did you IMMEDIATELY feel pain?
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Shoulder
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Arm
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Elbow
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Wrist
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Hand
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Fingers
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Buttock
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Hip
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Thigh
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Knee
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Calf
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Ankle
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Foot
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Toes
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In what areas did you IMMEDIATELY feel pain?
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Shoulder
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Field is required!
Arm
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Field is required!
Elbow
Field is required!
Field is required!
Wrist
Field is required!
Field is required!
Hand
Field is required!
Field is required!
Fingers
Field is required!
Field is required!
Buttock
Field is required!
Field is required!
Hip
Field is required!
Field is required!
Thigh
Field is required!
Field is required!
Knee
Field is required!
Field is required!
Calf
Field is required!
Field is required!
Ankle
Field is required!
Field is required!
Foot
Field is required!
Field is required!
Toes
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Field is required!
At the hospital, what areas were x-rayed?
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Shoulder
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Arm
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Elbow
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Field is required!
Wrist
Field is required!
Field is required!
Hand
Field is required!
Field is required!
Fingers
Field is required!
Field is required!
Buttock
Field is required!
Field is required!
Hip
Field is required!
Field is required!
Thigh
Field is required!
Field is required!
Knee
Field is required!
Field is required!
Calf
Field is required!
Field is required!
Ankle
Field is required!
Field is required!
Foot
Field is required!
Field is required!
Toes
Field is required!
Field is required!
Where did you experience pain on the day FOLLOWING the accident?
Field is required!
Field is required!
Shoulder
Field is required!
Field is required!
Arm
Field is required!
Field is required!
Elbow
Field is required!
Field is required!
Wrist
Field is required!
Field is required!
Hand
Field is required!
Field is required!
Fingers
Field is required!
Field is required!
Buttock
Field is required!
Field is required!
Hip
Field is required!
Field is required!
Thigh
Field is required!
Field is required!
Knee
Field is required!
Field is required!
Calf
Field is required!
Field is required!
Ankle
Field is required!
Field is required!
Foot
Field is required!
Field is required!
Toes
Field is required!
Field is required!
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Devine
Chiropractic & Rehab Center

Thank you for visiting Devine Chiropractic and Rehab Center.  Our clinic is located in downtown Seattle 98101, adjacent to Pike Place Market and a short walk from South Lake Union and Amazon buildings. Choosing the right doctor is an important decision to make.  Seattle Chiropractor James Devine and his team take pride in our ability to get our patients feeling better quickly and back to doing what they love.

devineoffice@devine-chiro.com

Seattle, WA 98101 USA

Hours

Mon – Fri: 7:30 AM – 6 PM.
Sat: 7:00 AM – 12:30 PM.

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