New Patient Info

Auto – Car Accident Doctor Buffalo, NY

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About
- Our Team
- Testimonials
Services
Forms
- New Patient Info
- Auto Accident Form
Contact Us

2018 New Patient Intake / Injury Questionnaire

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PATIENT INFORMATION (Section 1 of 6)

Today's Date

Form Identification Code

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Which number would you like to add? *

Home Telephone

Work Telephone

Cellular Telephone

Home Telephone Number *

Work Telephone Number *

Cellular Phone Nunber *

Email Address *

This will be your website username as well

Please make a selection *

Male

Female

Marital Status *

Married

Single

Divorced

Widowed

Date of Birth *

Would you like to provide your social security number?

Yes

No

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Social Security Number *

This form is secured by SSL Technology

Occupation *

Employer *

Have you ever received chiropractic care? *

Yes

No

When? *

Password *

Confirm Password *

Are you here because of a motor vehicle accident? *

Yes

No

Date of Accident *

Time of Accident *

:

Please describe how the accident happened *

What was your position in the vehicle *

Driver

Passenger Front

Passenger Left Rear

Passenger Right Rear

Passenger Middle Rear

Were your hands on the steering wheel? *

Yes

No

Which hand(s) *

Both Hands

Right Hand

Left Hand

Did the airbags deploy *

Yes

No

Did you strike another vehicle? *

Yes

No

Angle of Impact *

Front

Back

Left

Right

OtherOther

Was there a second collision? *

Yes

No

Did another vehicle strike you? *

Yes

No

Angle of Impact *

Front

Back

Left

Right

OtherOther

In relation to the back of your head, was your headrest set? *

Low

Middle

High

Were you surprised by the impact? *

Yes

No

Year of Vehicle *

Make of Vehicle *

Model of Vehicle *

What was your approximate speed when the accident occurred *

Approximate Year of other vehicle involved *

Approximate Make of other vehicle involved *

What was the approximate speed of other vehicle *

Were you wearing a seatbelt *

Yes

No

What type *

Lap Belt

Shoulder Belt

Both

Did you feel pain immediately following the accident? *

Yes

No

Were you rendered unconscious as a result of the accident *

Yes

No

Did you strike anything in the vehicle at the time of the impact *

Yes

No

What part of your body *

What did it strike?

Steering Wheel

Dashboard

Left Side Door

Left Window

Windshield

Roof

Right Side Door

Right Window

OtherOther

Did your seat break or bend? *

Yes

No

Immediately following the accident, how did you feel *

Dizzy

Dazed

Weak

Upset

Disoriented

Nervous

Nauseous

OtherOther

Check all that apply please

Were police notified? *

Yes

No

Were traffic citations issued? *

Yes

No

To Whom? *

Did you go to the hospital? *

Yes

No

When? *

How did you get there? *

Ambulance

Police Car

Private Transportation

Were you admitted? *

Yes

No

How long were you there? (Days) *

Name of Hospital *

Attended by Dr. *

Full name please

Treatment Given *

X-rays

Pain Medication

Stitches

Muscle Relaxants

Bandaged

Cervical Collar

Physical Therapy

Instructed Regarding Concussion

Instructed Regarding Sprains & Strains

Instructed to Call an Orthopedist

Instructed to Call a Private Physician

Referred to This Office

None

OtherOther

Have you seen any other doctor for this injury? *

Yes

No

Do you have difficulty in excessive *

Standing

Walking

Riding

Bending

Twisting

Do you have difficulty in excessive lifting *

Light

Moderate

Heavy

Repetitive

Any other symptoms other than the last 2 questions? *

Yes

No

Please tell us about them *

Signature *

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