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449 EAST FERRY STREET BUFFALO, NY 14208
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East Buffalo Chiropractic | Chiropractor Buffalo NY | Auto Accident | Car Accident | Doctor | Buffalo | NY
Auto – Car Accident Doctor Buffalo, NY | Chiropractor Buffalo NY
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Home
About
Our Team
Conditions
Services
Forms
New Patient Info
Auto Accident Form
Testimonials
Education
Attorney
Contact Us
Contact Us
My Account
Site Login
2018 New Patient Intake / Injury Questionnaire
PATIENT INFORMATION (Section 1 of 6)
Today's Date
Form Identification Code
First Name
*
Last Name
*
Address
*
City
*
State
*
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District of Columbia
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South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
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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
Our website is 100% secure utilizing the latest in security technology
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
*
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
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
Other
Other
Was there a second collision?
*
Yes
No
Did another vehicle strike you?
*
Yes
No
Angle of Impact
*
Front
Back
Left
Right
Other
Other
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
Other
Other
Did your seat break or bend?
*
Yes
No
Immediately following the accident, how did you feel
*
Dizzy
Dazed
Weak
Upset
Disoriented
Nervous
Nauseous
Other
Other
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
Other
Other
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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