MOORE CHIROPRACTIC CENTER 707 Sunset Street Denton, TX (940)

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Beverly Pitts
5 years ago
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1 MOORE CHIROPRACTIC CENTER 707 Sunset Street Denton, TX (940) Date Date of Accident File # ACCIDENT HISTORY REPORT Name Address City State Zip Children Date of Birth / / Sex M F Marital Status M S D W Spouse Do you smoke Yes-How many per day No Employer Occupation Home phone Work phone Cell phone Who may we contact in case of emergency? Phone Physician For Women Only: Date of last Period: / / Are you pregnant? Y N DESCRIPTION OF ACCIDENT (patient description) Driver Passenger (front ; Rear seat L R ) Pedestrian Other Were you wearing a seat belt? YES NO Were you wearing a shoulder belt? YES NO Did your vehicle strike another vehicle or object? YES NO - If yes describe: What was your Looking straight ahead head position? Looking left Deg. Looking right Deg. Looking up Deg. Looking down Deg. Hands: One on the wheel ( L or R ) Both hands were on wheel NA-was not driving Brake applied? YES NO Aware of the impending collision? YES NO Were you braced for the impact? YES NO Did you strike any object inside your car? YES NO Select the objects that you struck: Windshield Headrest Back of seat Seat broke Dashboard Steering wheel Door frame Side window Rearview mirror Rear window of pick-up Dazed cannot remember details Jarred or was thrown about 1

2 Head Face Chest Neck Back Shoulder(s) L / R Arm(s) L / R Elbow(s) L / R Wrist(s) L /R Leg(s) L / R Knee(s) L / R Ankle(s) L / R Were you: Other Unconscious Cut or bleeding (describe) Neither Model and year of your vehicle: Model and year of other vehicle(s): Estimated property damage to your vehicle: $ Estimated property damage to other vehicle(s): $ Did the air bag(s) deploy: YES NO NA If applicable, indicate any pain or abnormal sensations you experienced following the accident, when and where: Immediately Felt no immediate pain Pain began several hours after accident Pain began shortly after accident Head pain (headache) Semi-conscious state Neck pain Mid back pain - (L/R) Low back pain Between the shoulder blades Upper extremity pain (L/R) Lower extremity pain (L/R) Saw stars Nausea Confusion/disorientation Numbness and/or tingling: Where PAIN SCALE NO WORST 2

3 PAIN PAIN Were the police called to the scene? YES NO If yes, was a report made? YES NO PLEASE PROVIDE A COPY OF THE POLICE REPORT TO THIS OFFICE AS SOON POSSIBLE! Indicate the action you took immediately following the accident: Went home and took it easy Went about normal business Went to hospital Went home and later began to experience (neck/mid back/low back) pain Went home and later went to hospital I doctored myself thinking the pain would go away taking over the counter medication Went to medical doctor HOSPITALIZATION Indicate method of delivery to hospital: Ambulance Driven by spouse/relative/friend/employer I drove self Presbyterian Hospital of Denton Denton Regional Medical Center Other Hospital: City: Were you seen in the emergency room? YES NO Were you admitted to the hospital? YES NO Length of stay? Name (if known) of attending physician? Indicate any procedures performed at the hospital (including the emergency room): Examination Stitches X-Rays Physiotherapy (ex: ice, heat) Prescription Cervical collar Injection Wound dressed Complete bed rest MRI/CT Other Following your release from the hospital, where did you go? Returned home and took it easy. Returned home and went to bed. Returned home and returned to the emergency room after hours/days. Returned to work. IF DR MOORE IS THE FIRST DOCTOR YOU HAVE SEEN FOR THIS ACCIDENT, SKIP TO PAST HISTORY When did you first consult a physician? Same day Following day Within a few days Other: Who was the first physician consulted? Dr. Family physician Neurologist Chiropractor Orthopedist Osteopath (D.O.) Internist Family Walk-In Clinic Other 3

4 What was done? Examination Acupuncture X-Rays Collar/Support (belt/brace) Prescription Traction Manipulation & P.T. P.T. only Manipulation only Other Were you seen elsewhere for treatment? YES NO -If yes, where did you receive these treatments? Were you referred to any other physician or therapist? YES NO -If yes, where did you receive these treatments? Were you referred for any special diagnostic tests or examinations? YES (explain) NO MRI CT EMG NCV SSEP Other How long were you under the care of this physician? Are you still under the doctor s care? YES NO If no, when were you discharged? If yes, indicate the frequency of your visits to the doctor. Other pertinent information: PAST HISTORY Have you ever had any previous accidents or injuries? No Yes - Give dates and details: Have you ever been previously treated for neck and/or back problems? Please explain: Have you been previously treated by a Doctor of Chiropractic? Please explain: Past surgical history and/or conditions? Please explain: 4

5 Have you had any significant medical problems? (Diabetes; heart; lungs; high blood pressure; broken bones; etc.) Have any of your blood relatives had? (Diabetes, heart, lungs, high blood pressure, broken bones, etc.) Did you enjoy good health prior to this accident? YES NO - explain: List all medications presently taking: DISABILITY Have you lost any time from work since the accident? NO YES - number of days lost: Are you still off from work? YES NO - Indicate the date you returned to work: Are you working at this time? YES NO Are you working with any restrictions? NO YES - What are the restrictions: Signature: Patient/Guardian 8/6/2008 ACCIDENT HX RPT (F)MCC FORMS DOCTORS INITIALS: 5

Personal Injury Questionnaire. Name: Address: City: State: Zip: Cell Phone: Home phone: Work Phone: Social Security Number:

Personal Injury Questionnaire. Name: Address: City: State: Zip: Cell Phone: Home phone: Work Phone: Social Security Number: Personal Injury Questionnaire Name: Address: City: State: Zip: Cell Phone: Home phone: Work Phone: Social Security Number: Email: Date of birth Sex: Male Female Marital States S M D W Date of Accident: