History of Accident .pdf

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Patient Name: ___________________________________
DOB: __________________________________________

Acct#____________________________________
Claim#___________________________________

History of Accident
Description of Accident
Date of accident:_____________ Time:_________ Driver of car:________________ Owner of car:_______________
Year and model of car:_________________________________
Where were you seated?  Front Left  Front Right  Rear Left  Rear Middle  Rear Right
Where was the accident? City:__________________ Street:___________________ Cross Street:___________________
Direction of Travel:_____________
Your car:  Hit another car
 Was hit by another car on the:  Right  Left  Rear  Front  Side
Type of Accident:  Head-on collision  Broadside collision  Rear end collision
 Front impact, rear-ended car in front  Other
Please describe how the accident happened: (you can also draw what happened)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Was your car braking?  Yes  No Was your car moving at the time of accident?  Yes  No
If yes, how fast? ____________MPH (estimate)
How fast was the other car traveling? _________MPH(estimate)
Did police come to the accident scene?  Yes  No Did an ambulance come to the accident scene?  Yes  No
Were you transported by ambulance to the hospital?  Yes  No If yes, what hospital? ________________________
During Accident
What kind of seat belt were you using?  Lap belt  Shoulder belt  Both  None
Were you aware the accident was about to happen?  Yes  No
Did you brace for the impact?  Yes  No  Not sure
What was the position of the headrest compared to your head before the accident?
 Top of headrest even with bottom of head  Top of headrest even with top of head
 Top of headrest even with middle of neck  Unknown
Head/body position at the time of impact:
 Head turned left  Head turned right  Head looking back  Head forward
 Body straight in sitting position  Body rotated left  Body rotated right
Position of arms at time of impact: (ie: on steering wheel)___________________________________________________
Position of feet at time of impact: (ie: on brake)____________________________________________________________
Describe what happened to you upon impact: _____________________________________________________________
__________________________________________________________________________________________________
At the time of impact, recall what parts of your head or body hit what parts on the inside of the car:__________________
__________________________________________________________________________________________________
Total Family Chiropractic, PC D. Scott Conklin, DC 4309 SE Woodstock Blvd #120 Portland, OR 9720 503-777-4221

Page 1

Patient Name: ___________________________________
DOB: __________________________________________

Acct#____________________________________
Claim#___________________________________

After the accident, were you:  Rendered unconscious  Dazed, circumstances vague  Shaken up, but could function
Could you move all parts of your body?  Yes  No
If not, what body parts could you not move, and why? _______________________________________________
Were you able to get out of the car and walk unaided? Yes No If no, why not?______________________________
Did you get any bleeding, cuts, or bruises? Yes No If yes, please describe_________________________________
After the Accident
Please describe how you felt immediately after the accident. Be specific.________________________________________
__________________________________________________________________________________________________
How did you feel later that day/night?___________________________________________________________________
The next days?______________________________________________________________________________________
Did you have any physical complaints just before the accident?  Yes  No
If yes, please describe:_________________________________________________________________________
Activities of Daily Living
Do you notice any of your home activities that are different now than before the accident?  Yes  No
If yes, what activities are you now unable to do?____________________________________________________
What activities are now painful to do?_____________________________________________________________
What activities are now difficult to do?____________________________________________________________
Work Status History
Have you missed time from work?  Yes  No
If yes, what dates?____________________________________________________________________________
Treatment
Did you seek treatment at any hospital or clinic before coming here?  Yes  No
If yes….
First Hospital/Clinic Seen________________________________________________ Date Seen:___________________
Were you examined?  Yes  No Were x-rays taken?  Yes  No
Were you given treatment?  Yes  No If yes, what treatment?___________________________________________
What benefits did you receive from the treatment?_________________________________________________________
Date of last treatment: ___________________
Second Hospital/Clinic Seen______________________________________________ Date Seen:___________________
Were you examined?  Yes  No Were x-rays taken?  Yes  No
Were you given treatment?  Yes  No If yes, what treatment?___________________________________________
What benefits did you receive from the treatment?_________________________________________________________
Date of last treatment: ___________________

Total Family Chiropractic, PC D. Scott Conklin, DC 4309 SE Woodstock Blvd #120 Portland, OR 9720 503-777-4221

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