Auto Injury Patient Intake

    Auto Injury Patient Paperwork

    AUTO INJURY INFORMATION

    Patient Name (required)

    Patient's Email (required)
    (Or guardian's email if patient is a minor) *Email is required because we will send you your scan and evaluation results*

    Patient's Cell Phone # (required)
    (Or guardian's cell if patient is a minor)

    Patient's Address (required)

    Patient's Zip Code (required)

    Birthdate (required)

    Patient Age (required)

    Patient Gender (required)

    Patient Marital Status (required)

    Do You Have Children? (required)

    Occupation Status: (required)

    Employer (required)
    (If not employed, put N/A)

    Emergency Contact Name (required)

    Emergency Contact Phone 1 (required)

    Emergency Contact Phone 2

    Emergency Contact Employer (required)

    How were you referred to our office? (required)

    AUTO INJURY QUESTIONNAIRE

    Your Auto Insurance Company (required)

    Name on Policy (required)

    At-Fault Auto Insurance Company (required)

    Claim # (required)

    At-Fault Auto Insurance Phone # (required)

    At-Fault Auto Insurance FAX #
    (Optional)

    Do you have an attorney? (required)

    Date of Accident (required)

    Time of Day (required)

    Were you: (required)

    Number of people in the vehicle: (required)

    Were you wearing a seat belt? (required)

    Were you struck from: (required)

    Speed of your car: (required)

    Speed of the other car: (required)

    Were you knocked unconscious? (required)

    Were police notified of the accident? (required)

    What is the make of your car? (required)
    (Example: Toyota, Honda, Ford...)

    What is the model of your vehicle? (required)
    (Example: Camry, CR-V, F-150....)

    What year is your vehicle? (required)

    How much damage was done to your vehicle? (required)

    In your own words, please describe the accident: (required)

    Did you have any physical complaints BEFORE THE ACCIDENT? (required)

    Describe how you felt during the accident: (required)

    Describe how you felt immediately after the accident: (required)

    Describe how you felt later that day, after the accident: (required)

    Where were you taken after the accident? (required)

    What type of treatment did you receive after the accident? (required)

    What other doctors have treated you since the accident? (required)
    (If NONE put "N/A"

    Since the accident, are your symptoms: (required)

    Have you lost time from work as a result of this accident? (required)

    Have you noticed any activity restrictions as a result of the accident? (required)

    SYMPTOMS QUESTIONNAIRE

    Please select symptoms you're experiencing. (required)
    This section is focused on misalignment of the neck region.

    Please select symptoms you're experiencing. (required)
    This section is focused on misalignment of the mid-back region.

    Please select symptoms you're experiencing. (required)
    This section is focused on misalignment of the low back region.

    Please select symptoms you're experiencing. (required)
    This section is focused on misalignment of the pelvis.

    EXPERIENCE WITH CHIROPRACTIC CARE

    Have you seen a chiropractor before? (required)

    Did you know posture determines your health? (required)

    Are you aware of any poor posture habits? (required)

    Are you aware of any poor posture habits in your spouse or children? (required)

    HEALTH LIFESTYLE

    Do you exercise (required)

    Do you smoke? (required)

    Do you drink alcohol? (required)

    Do you drink coffee? (required)

    Do you take any health supplements (vitamins, minerals, herbs, etc.)? (required)

    Please list any health conditions not mentioned above: (required)
    *Put "N/A" if not applicable

    Please list any medications you are currently taking and their purpose: (required)
    *Put "N/A" if not applicable

    Please list all past surgeries: (required)
    *Put "N/A" if not applicable

    Please list all previous accidents and falls: (required)
    *Put "N/A" if not applicable

    TERMS OF ACCEPTANCE & CONSENT TO CARE

    TERMS OF ACCEPTANCE When a person seeks chiropractic health care and is accepted for such care, it is essential for both parties to be working towards the same objective. We have one main goal, to detect and correct/reduce the vertebral subluxation complex. It is important that each person understand both the objective and the method that will be used to attain this goal. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express it's maximum health potential. We do not offer to diagnose or treat a disease or condition other than vertebral subluxation. Regardless of what a disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our Only Practice Objective is to eliminate a major interference to the expression of the body's innate wisdom and ability to heal. Our only method is specific adjusting to correct vertebral subluxations. N01E: It is understood and agreed the amount paid to Revelation Chiropractic for x-ray, is for examination only and the x-rays will remain the property of this office, being on file where they may be seen at any time while a patient of this office.

    CONSENT TO CARE I do hereby authorize the doctors of Revelation Chiropractic to administer such care that is necessary for my particular case. This care may include consultation, examination, spinal adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays or any other procedure that is advisable, and necessary for my health care. Furthermore, I authorize and agree to allow Revelation Chiropractic to work with my spine through the use of spinal adjustments and rehabilitative exercises for the sole purpose of postural and structural restoration to allow for normal biomechanical motion and neurological function. I have had an opportunity to discuss with the doctor of chiropractic and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures related to my health care. I understand that I am responsible for all fees incurred for the services provided, and agree to ensure full payment of all charges. I further understand that a fee for services rendered will be charged and that I am responsible for this fee whether results are obtained or not. I also clearly understand that if I do not follow the Doctors specific recommendations at this clinic that I will not receive the full benefit from the programs offered, and that if l terminate my care prematurely that all fees incurred will be due and payable at that time. I authorize the assignment of all insurance benefits be directed to the Doctor for all services rendered. I also understand any sum of money paid under assignment by any insurance company shall be credited to my account, and I shall be personally liable for any and all of the unpaid balance to the doctor.

    TERMS OF ACCEPTANCE & CONSENT TO CARE*

    *Before you Click The Button Below to Submit the form, please be sure you have filled out all Required fields above.

    - If you have completed the form correctly, after you click the button below you will be directed to a "Thank You" page.

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