A Family Chiropractic offers our patient form(s) online so they can be completed it in the convenience of your own home or office.
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- Fax us your printed and completed form(s) or bring it with you to your appointment.
New Patient Health History Form - Required
This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!
Got in a Car Accident? Fill out this Extra Pain to Help Streamline Your Appointment
PERSONAL INJURY QUESTIONNAIRE
Name:__________________________________________________ Phone:______________ __________
Address:________________________________ City:__________________ State:________ Zip:_______
Age:_________ Birthdate:___________________ Sex:_________ S/S #:___________________________
Employer:_____________________________ Employer’s Address:_______________________________
Your Car Ins. Co.:_______________________________ Policy #:________________________________
Claims Adjustor’s Name:_________________________ Phone #:_________________________________
Claim Number: _________________________________________________________________________
Attorney’s Name:__________________________________ Phone #:______________________________
Address:________________________________ City:___________________ State:________ Zip:______
If you were not the driver of your car:
Name on Policy of Driver of Your Car:________________________ Driver’s Policy’s #:______________
Address:________________________________ City:__________________ State:________ Zip:_______
Their Car Ins. Co.:_______________________________ Policy #:________________________________
Claims Adjustor’s Name:_________________________ Phone #:_________________________________
Claim Number: _________________________________________________________________________
Attorney’s Name:__________________________________ Phone #:______________________________
Address:________________________________ City:___________________ State:________ Zip:______
Other Party’s Name:____________________________________ Policy’s #:________________________
Address:________________________________ City:__________________ State:________ Zip:_______
Their Car Ins. Co.:_______________________________ Policy #:________________________________
Claims Adjustor’s Name:_________________________ Phone #:_________________________________
Claim Number: _________________________________________________________________________
Attorney’s Name:__________________________________ Phone #:______________________________
Address:________________________________ City:___________________ State:________ Zip:______
Who was the responsible party:_____________________________________________________________
Was their a police report filed:______________________________________ If yes, please provide a copy
Nature of Accident:
1. Date of accident:____________________________ Time of Day:______________________________
2. Were you: ( ) Driver ( ) Passenger ( ) Front Seat ( ) Back Seat
3. Number of people in your vehicle: ___________ Number of people wearing seat belts:_____________
4. What direction were headed: ( ) North ( ) South ( ) East ( ) West
on (name of street):____________________________________________________________________
5. What direction was the other vehicle heading: ( ) North ( ) South ( ) East ( ) West
on (name of street):____________________________________________________________________
6. Were you struck from: ( ) Behind ( ) Front ( ) Left side ( ) Right side
7. Approximate speed of your car: ________________mph Other car: ________________mph
8. Were you knocked unconscious: ( ) Yes ( ) No If yes, for how long:_____________________
9. Were the police notified: ( ) Yes ( ) No
10. In your own words, please describe accident: ______________________________________________
____________________________________________________________________________________________________________________________________________________________________________
11. Did you have any physical complaints BEFORE THE ACCIDENT: ( ) Yes ( ) No
If yes, please describe in detail:__________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
12. Please describe how you felt:
a) During the accident:____________________________________________________________
b) Immediately after the accident:____________________________________________________
c) Later that day:_________________________________________________________________
d) The next day:__________________________________________________________________
13. What are your PRESENT complaint and symptoms:_________________________________________
____________________________________________________________________________________________________________________________________________________________________________
14. Do you have any congenital (from birth) factors which relate to this problems: ( ) Yes ( ) No
If yes, please describe in detail:__________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
15. Do you have any previous illnesses which relate to this case: ( ) Yes ( ) No
If yes, please describe in detail:__________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
16. Have you have been involved in an accident before: ( ) Yes ( ) No
If yes, please describe in detail, including date(s) and type(s) of accidents, as well as injury(ies) recieved:____________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
17. Where were you taken after the accident:__________________________________________________
18. Have you been treated by another doctor since the accident: ( ) Yes ( ) No
If yes, please list doctor’s name and address:_______________________________________________
____________________________________________________________________________________________________________________________________________________________________________
19. Since this injury occurred, are your symptoms: ( ) Improving ( ) Getting Worse ( ) Same
20. CHECK SYMPTOMS YOU HAVE NOTICED SINCE ACCIDENT:
[ ] Headache [ ] Irritability [ ] Numbness in Toes [ ] Face Flushed [ ] Feet Cold
[ ] Neck Pain [ ] Chest Pain [ ] Shortness in Breath [ ] Buzzing in Ears [ ] Hands Cold
[ ] Neck Stiffness [ ] Dizziness [ ] Fatigue [ ] Loss of Balance [ ] Stomach Upset
[ ] Sleeping Problems [ ] Head Seems Too Heavy [ ] Depression [ ] Fainting [ ] Constipation
[ ] Back Pain [ ] Pins & Needles in Arms [ ] Light Bothers Eye [ ] Loss of Smell [ ] Cold Sweats
[ ] Nervousness [ ] Pins & Needles in Legs [ ] Loss of Memory [ ] Loss of Taste [ ] Fever
[ ] Tension [ ] Numbness in Fingers [ ] Ears Ring [ ] Diarrhea [ ] _____________________
Additional symptoms other than the above___________________________________________________
21. Have you lost time from work as a result of this accident: ( ) Yes ( ) No If yes, please complete:
a) Last Day Worked:___________________________________________________________________
b) Type of Employment:________________________________________________________________
c) Present Salary:_____________________________________________________________________
d) Are you being compensated for time lost from work: ( ) Yes ( ) No If yes, please state type
of compensation you are receiving:______________________________________________________
22. Do you notice any activity restrictions as a result of this injury: ( ) Yes ( ) No
If yes, please describe in detail:__________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
23. Other pertinent information:____________________________________________________________ ______________________________________________________________________________________
______________________________________________________________________________________
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I authorize and request my insurance company to pay directly to the chiropractor. I understand that my chiropractic insurance company may pay less than the actual bill of service. I agree to be responsible for payment of all services rendered on my behalf or dependents.
___________________________________________ ___________________________
Signature Date
Member Wellness Registration Form - Optional
This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!
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100 O'Connor Dr. #25 San Jose, Ca 95128 408.271.2800
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