Patient Registration Form

Last Name

First Name

M.I.

Nickname

Address

City

State

Zip Code

Mobile Phone

Home Phone

Office Phone

SSN

Date of Birth

Age

Gender

Marital Status

Employer Name

Occupation

Spouse Name

Phone Number

Spouse Employer/ Occupation

Children Names/ Ages

Date of Injury

Injury Description

If your injury is NOT due to an automobile collision, please skip to the section titled “Areas of Complaint”

UPON IMPACT (Please Answer the option that applies) :

Were you stopped?

If No, approximate speed in mph?

Was the other vehicle stopped?

If no, other vehicle speed in mph?

Was your body straight in your seat?

If no, turned to the?

Were you looking straight ahead?

If No, what direction did you turn your head?

Were you aware that you were about to be hit?

Were you wearing a seatbelt at the time of the accident?

Did your chest / head hit the steering wheel?

Did an airbag deploy?

Did your head hit the Windshield?

Did your shoulder hit the door?

Did your knees hit the dashboard?

Did the seat break?

Cuts or Bruises

Cuts and Bruises Yes/ No

Cuts/ Bruises if Yes, where?

Vehicle Equipped with Headrests?

Height for Top of Headrest

Did you lose consciousness?

If so, for how long?

On a scale of 1-10, please rate your pain level.

Pain Scale

Are you experiencing any of the following since your injury? (Check all that apply)

Dizziness/Loss of balance

Headaches

Upper Back Pain

Neck Pain

Mid Back Pain

Low Back Pain

Wrist/Hand Pain

Elbow Pain

Hip Pain

Pain in Knee

Pain in Ankle

Foot Pain

Numbness/Tingling to leg

Numbness/Tingling to arm

Shoulder Pain

Chest Pain

Anxiety

Fatigue

Sore Throat

Breathing Problems

Digestive or Urinary

TREATMENT INFORMATION

List all the doctors that you have seen as a result of your injuries:

Date/Doctor/Hospital Treatment 1

Date/Doctor/Hospital Treatment 2

Date/Doctor/Hospital Treatment 3

Do you have any future appointments with any doctor regarding your injuries?

Medications

Please list all past surgeries, major illnesses or diseases, hospitalizations (with approximate date)

Please list any previous accidents and injuries:

Family History

Mother’s Side:

Mother's Side Other:

Father’s Side:

Father's Side Other

For Women:

Pregnant

Pregnancy Yes, Weeks?

SUBMIT

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