Personal Injury Intake Form

Personal Injury Intake New Patient

Please complete this form prior at least 24 hours prior to your appointment. If you have a police report from your accident you can leave the accident details blank and provide us a copy of the accident report.
Name*

First NameLast Name
If your preferred name is different than your given name, please enter below:
Please enter your date of birth*

MonthDayYear
Please enter your social security number - **please note**we are unable to set up any type of payment plan without a social security number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Who referred you to our office?*

a friendmy doctorGoogle/internet searchmy health insurance
If referred by friend, family or your physician, please provide their name:
Please provide a contact in case of emergency*

First NameLast Name
Emergency contact phone number *

Area CodePhone Number
Please enter the date of your accident:*

MonthDayYear
Date
Is this accident work related?

yesno
Were the police called to the accident?*

Yes, and an accident report is available.NoOther
Which seat did you occupy in the vehicle at the time of impact?*

driverpassengerrearOther
Were you wearing a seatbelt?*

YesNo
Did the airbag deploy?*

YesNo
Which statement describes your knowledge of the accident?

I was completely surprised and did not see it comingI saw it coming
Please describe, to the best of your knowledge, what happened during the accident.*
Please select most appropriate statement below regarding your medical treatment after the accident.*

I was treated immediately afterwards at an Urgent Care or Emergency DepartmentI did not seek medical treatment immediately afterwardsOther
What treatment have you received after Urgent Care / Emergency Room*

Chiropractic carePhysical therapyPrimary care follow upno treatment receivedOther
Auto Insurance Information

Please complete this section entirely. If you are using health insurance or self-pay please skip this section.
Who was the driver of the automobile you were in?*

First NameLast Name
Please choose which option best applies*

I am the responsible party in the accidentThe other party was the responsible party in the accidentSomeone else was responsible, but we will be filing my auto insurance
Name of the auto insurance carrier*
Policy number
Claim number *
Who is the claim adjuster?

First NameLast Name
Claim adjuster phone number

Area CodePhone Number
If possible, please attach a picture of the front of your auto insurance card

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Who is the driver of the other vehicle?

First NameLast Name
Name of the other party's auto insurance carrier*
Other party's Policy number
Other party's Claim number *
Who is the other party's claim adjuster?*

First NameLast Name
Other party's Claim adjuster's phone number*

Area CodePhone Number
If possible, please attach a picture of the front of the other party's auto insurance card

Browse Files

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Attorney information

If you have retained an attorney, please enter their information below. If not, please skip this step. If at any point during or after your treatment you retain an attorney regarding this automobile accident, please be sure to notify us and provide us with their contact information.
Attorney name

First NameLast Name
Attorney phone number

Area CodePhone Number
Health insurance policy information

Your auto insurance or the responsible party's auto insurance may cover your health care costs. If you would like us to bill the auto insurance carrier(s) for your treatment please be sure we have all necessary policy information.
Please select the name of your health insurance provider*

Auto insurance carrier is responsible, do not bill my health insuranceBlue Cross Blue ShieldCignaMedcostUnited HealthcareAetnaMedicareOther
Subscriber ID / Member ID
This is generally listed on the front of your insurance ID card and may be alpha numeric. Please include all characters listed including any listed suffix (01,02,03, etc)
Group number
Please list your relationship to the insured

I am the policy holderMy spouse is the policy holderI am a dependent of the policy holderNo insurance/ Cash patient
Provider services phone number (usually listed on the back of the ID card)

Area CodePhone Number
If you are not the policy holder, please enter the policy holder's name

First NameLast Name
Policy holder's date of birth (mm/dd/yyyy)

MonthDayYear
Date
If possible, please attach a picture of the front of your insurance card

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If possible, please attach a picture of the back of your insurance card

Browse Files

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Current condition information

Please use the following fields to describe what brings you into our office today.
Please list your health concern(s)*
Please use the drawing tool to circle your area of complaint (s)
Please rate your pain on a scale of 0-10, 10 being the worst.*
The quality of my pain listed above is characterized as*

burningstabbingdull/achestiffpins and needles / tingling
This pain is*

constanton and off
Does this pain radiate/shoot to other areas of the body?*

yesno
If you answered yes the the last question (your pain radiates), please select which areas are affected

shoulder / arm / hands / fingersbuttocks / legankle / footrightleftboth right and left
Please list all things which make your pain better*

iceheatrestmovement / position changesittingstandingstretchingRx medicationOTC medicationOther
Please list all the things which make your pain worse*

sittingstandingmovement / position changewalkinglying downsleepingheatOther

Please indicate how your condition impacts the following activities of daily living*

	painful	some pain	not affected
bending
lifting
stairs
sitting
standing
walking
exercising
housework
kneeling

Please list any other providers who have treated this condition*

my primary care physicianorthopedic doctormassage therapistphysical therapistanother chiropractor
Please list any imaging you have had in the last three months*

spinal xrayspinal MRIOther
Lifestyle history

Please complete the following fields to the best of your ability. This information will help us with your case and should not be left blank.
Please list any supplements and over the counter medications you currently take*
Please list any prescription medications you are currently taking*
Do you use tobacco products?

NoYesOccasionally
Which statement best describes your exercise habits

I exercise regularly and frequently (3+ times per week on a regular basis)I exercise regularly but in-frequently (1-2 times per week on regular basis)I exercise every once in a whileI don't exercise
How often to you consume alcoholic drinks?

rarely / never1-3 drinks per week3-5 drinks per weekover 6 drinks per week
Which statement best describes your eating habits?

I eat fast food regularly (3+ times per week)I eat out sometimes and make healthy choicesI eat clean (organic, whole foods most of the time)Other
Health history

Please fill out the following information to the best of your ability. If you have no symptoms listed be sure to check the last box "none in this category"
General:*

recent unintentional weight lossfeverextreme fatiguenone in this category
Musculoskeletal*

broken bonesprevious surgery (please explain in next section)none in this category
Neurological*

numbness or tingling sensationsloss of feelingdizziness or lightheadedfrequent or recurrent headacheshead injury / concussionnone in this category
Gastrointestinal*

loss of apetitebloody stoolconstipationdiarrheanausea or vomittingregular abdominal pain / bloatingnone in this category
Cardiovascular / heart*

chest painrapid or heartbeat changesblood pressure regulation problemshigh cholesterolswelling of ankles and feetnone in this category
Respiratory*

difficulty breathingpersistent coughasthmacoughing bloodnone in this category
Eyes / vision*

blurred or double visioneye disease or injurywear glasses / contactsnone in this category
Genitourinary*

kidney stonesburning / painful urinationfrequent urinationurinary leakage / bed wettingblood in urinenone in this category
Endocrine, hematologic, lymphatic*

thyroid problemsdiabetescold hands / feetimmune system disordernone in this category
Skin and breasts*

rash / itchingnon-healing soresbreast painbreast lumpnone in this section
Are you pregnant?

yesnoit's possible
If yes, what is your estimated date of delivery?

MonthDayYear
Date
Do you have an immediate family history of any of the following? (check all that apply)*

cancerheart diseasestrokeno familial history of any of these conditions
Please list any surgeries in the field below. List surgery type and year performed.
HIPAA Privacy Practices Below
I have reviewed the HIPAA Privacy Practices for Gard Wellness Center (above)*

Clear
You're done! Thank you for completing this form, click 'Submit' below and we'll receive your information. We look forward to helping you life life well!
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Personal Injury Intake New Patient

Auto Insurance Information

Attorney information

Health insurance policy information

Current condition information

Lifestyle history

Health history