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Personal Injury- Auto/Cycle Accident History Please Print all responses and ask for assistance if you have any questions.

Patient Information

Name ______________________________________________Today’s Date______________ Street Address________________________________________________________________ City _____________________________ State ______________________ Zip ____________ Home Phone ___________________________ Cell Phone____________________________ Loss/Accident?___________ Date you first saw any Doctor after accident___________ Date of Birth __________E-Mail: _____________________Social Security #______________ Street Address________________________________________________________________ City _____________________________ State ______________________ Zip ____________ Home Phone ___________________________ Cell Phone____________________________ Occupation__________________________________________________________________ Employer ________________________________ Business Phone _____________________ Employer’s Address:__________________________________________________________ Sex: □ Male □ Female Height_______________ Weight ___________________ Dominant Hand? □ Right □ Left Driver License #________________________________ Are you: □ Married □ Single □ Domestic Partnership □ Divorced □ Separated □ Widowed Spouses Name: ___________________________ # of Children________________________ Emergency Contact Name ___________________________ Relationship________________ Emergency Contact Phone ______________________________________________________ Health Insurance Carrier_____________________________ Policy#____________________ Address_________________________________________ City____________ Zip________ Adjuster________________________________________ Phone_______________________ Car Insurance Company________________________________________________________ Address__________________________________________ City__________ Zip_________ Adjuster________________________________________ Phone_______________________ Agent__________________________________________ Phone_______________________ Policy#_______________________________________ Claim Number _________________ Was the vehicle registered to you? □ yes /□ no. Who was it registered to?________________ What Medical Payments Coverage? _________ What Uninsured Motorist Coverage?_______ Other Party’s Insurance Carrier _______________________ Claim Number ______________ Adjuster________________________________________ Phone_______________________ What Law Firm Represents You?_________________________________________________ Address__________________________________________ City____________ Zip________ Name of Attorney__________________________________ Phone Number ______________ Name of Insured on your Car Policy_______________________________________________ Cost of all medical treatment since the accident? $___________________________________ How much income have you lost since the accident? $________________________________ What is the property damage (repair amount) of your car? $____________________________ Do you have any special needs? _________________________________________________ How did you hear about us?_____________________________________________________

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Was anyone else in the vehicle with you at the time of the collision: □ yes □ no, If yes, identify all persons below: Name Relationship Age Injured? 1.____________________________________ ___________________ ____ □yes □no □unsure 2.____________________________________ ___________________ ____ □yes □no □unsure 3.____________________________________ ___________________ ____ □yes □no □unsure 4.____________________________________ ___________________ ____ □yes □no □unsure 5.____________________________________ ___________________ ____ □yes □no □unsure

Location of the accident:________________________________________________________ Name of your Personal M.D.____________________________ Phone___________________ Address___________________________________________City_____________ Zip_______

History “Crash Description” Accident/Injury/Onset What was your position in the vehicle? □ Driver □ Front Passenger □ Rear Passenger □ Pedestrian (not in car) What type of vehicle were you driving? □ Compact Car □ Mid Size Car □ Full Size Car □ Compact Truck □ Full Size Truck □ Mini Van □ Full Size Van □ Small Sport Utility □ Large Sport Utility □ Motorcycle □ Motor Home □ Bicycle Your vehicle (year, make, model)____________________ What was your vehicle doing just prior to the accident? □ Stopped at a stop light □ Slowing down to a stop □ At a complete stop □ Increasing speed □ Merging into traffic □ Changing lanes

Traveling at an approximate speed of: □ 5 mph □ 10 mph □ 15 mph □ 20 mph □ 25 mph □ 30 mph □ 35 mph □ 40 mph □ 45 mph □ 50 mph □ 55 mph □ 60 mph □ 65 mph □ 70 mph □ 75 mph □ 80 mph □ Faster than 80 mph Who hit who? □ You were struck by another vehicle □ You struck another vehicle □ You stuck a stationary object What was your vehicles point of impact? □ Front □Rear □ Right Side □ Left Side □ Right Front □ Left Front □ Right Rear □ Left Rear What was the other vehicle doing just prior to the accident? □Stopped at a stop light □Slowing down to a stop □At a complete stop □Increasing speed □Merging into traffic □Changing lanes Total number of vehicles involved in the collision: _____ Total number of impacts to your vehicle: _____ □yes □no Was the side(s) of your vehicle impacted?

Traveling at an approximate speed of: □ 5 mph □ 10 mph □ 15 mph □ 20 mph □ 25 mph □ 30 mph □ 35 mph □ 40 mph □ 45 mph □ 50 mph □ 55 mph □ 60 mph □ 65 mph □ 70 mph □ 75 mph □ 80 mph □ Faster than 80 mph What was the other vehicles point of impact? □ Front □Rear □ Right Side □ Left Side □ Right Front □ Left Front □ Right Rear □ Left Rear Were you wearing seat restraints? □ Full lap and shoulder restraint □ Lap restraint only □ Shoulder restraint only □ I was not wearing a restraint

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What position were your vehicles head rests in? □ Lowest position □ Middle position □ Highest Position □ No head rest in vehicle Did your vehicle air bags deploy? □Yes □No Were you prepared for the impact? □ Came as complete surprise □ Aware and braced for collision □ Aware but not braced for collision What position was your head and neck in prior to the impact? □ Straight forward □ Tilted forward □ Rotated to the left □ Rotated to the right □ Turned around □ Toward rear view mirror What happened to your body at the moment of Impact? □ Body was tensed for impact □ Body torqued and twisted □ Body was thrown from vehicle □ Body was thrown from side to side □ Body whipped forward/backward □ Body was thrown over seat □ Body was pinned in vehicle □ Body was cut and bruised What was your mental/emotional state immediately following? □ Unconscious □ Disoriented □ Shaken up □ Shaken up & Disoriented Did you strike anything within the vehicle with your body part? □ Yes □ No Please identify and list all areas of your body that struck the below listed parts of your vehicle: Also, please draw a line from the item impacted to the part of the body struck. (eg. Front, Back, Right, Left, Head, Neck, Shoulder, Arm, Elbow, Wrist, Hand, Chest, Stomach, Hip, Knee, Ankle, Foot) □ Dashboard: __________________________________□

□ Windshield: _________________________________ □

□ Side Window: _______________________________ □

□ Steering wheel: ______________________________□

□ Right inner door panel: ______________________□

□ Left inner door panel: _______________________□

□ Seat frame: __________________________________□

□ Head rest: ___________________________________□

□ Air Bags: ____________________________________□

□ Gear selector: ________________________________□

□ Ceiling: ______________________________________□

□ Armrest: _____________________________________□ □ ______________________________________________□ □ ______________________________________________□ Was there any cuts? □ Yes □No, If yes where on body:_________________________□ _______________________________________________________________________________ Was there any bruises? □ Yes □No, If yes where on body:_____________________________□ ______________________________________________________________________________________ Was there any Abrasions (rubs or scrapes against the skin)? □ Yes □No, If yes where on body:_____□ ____________________________________________________________________________________________ Was there any Photo’s taken? □ Yes □No Was the crash on-the-job? □Yes □ No If yes, was it reported to your employer? □ yes □ no Time of day: □ Day light □ Dawn □ Dusk □ Dark

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Road conditions: □Dry □Damp □Wet □Snow □Ice □Other_________________________

Was the seat broken? □Yes □No Hands: □One □Two on steering wheel Brakes applied? □Yes □No Did any windows break in your vehicle? □ Yes □No If yes, please identify:_________________

Was there any “flying” glass from the impact? □ Yes □No If yes, Please identify:___________

Make, model of the vehicle and year of vehicle you were in:_______________________________

Describe any damage done to the vehicle you were in:______________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ____________________________________________________________Photo’s taken? □ yes □ no Estimated damage to vehicle you were in: □None □Minimal □Moderate □Major Make, model of the vehicle and year of the other vehicle:___________________________________

Describe any damage done to the other vehicle (s):________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ____________________________________________________________Photo’s taken? □ yes □ no Estimated damage to other vehicle(s): □None □Minimal □Moderate □Major

Please describe, in detail, how the collision happened: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Please diagram the accident diagram below:

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What was your condition during and immediately after crash? Where you wearing hat or glasses? □ Yes □No If yes, where they still on after crash? □Yes □No Did you lose consciousness at any time? □Yes □ No If yes, for how long? ___________________

Did you lose bowel or bladder control? □Yes □ No__________________________________________

Did you have facial numbness/Speech problems? □Yes □ No__________________________________

Did you have any extremity numbness/weakness? □Yes □ No__________________________________

Symptoms: □Headache □Spasm □Dizziness □Visual Disturbance □Nausea □Confusion/disorientation □Neck pain □Parethesia(s) □Extremity pain □Mid back pain □ Vomiting □ Fatigue □Malaise □Weak □Lightheaded □ Vertigo □Anxiety □ Tinnitus □ Stiffness □ Radiating Pain □ Depression □Low back pain □TMJ __________________________________________________________________________________________________________________________________________________________________________________________ What was your condition later that same day?__________________________________ _____________________________________________________________________________ What was your condition next day?____________________________________________ ____________________________________________________________________________ Where you able to get out of the vehicle on your own? □Yes □ No If not, who help you? ____________________________________________________________________________________________ If you were assisted out of your vehicle, describe how you were removed: _____________________ ____________________________________________________________________________________________ Did you receive any first aid at the scene? □Yes □ No If yes, by whom?_______________________

If applicable, what first aid was provided to you at the scene?_________________________________

Who was called or came to the on-scene accident? (Mark all that applies) □Highway Patrol □Local Police □Sheriff □ Paramedics □ Ambulance □other________________

Was a report made? □Yes □ No If yes, do you have a copy? □Yes □ No □ Not yet, but I will provide it. Did you receive medical attention at the scene of the accident? □ Yes □ No Where did you go immediately following the accident? □ Hospital Emergency Department by Ambulance □ Hospital Emergency Department was driven by □ self □ other □ Home □ Personal Doctor □ Resumed daily activities □This Office □ Urgent care Please identify where you went and who attended you there:_________________________________ ___________________________________________________________________________________________ What was done for you there? Exam: □ Yes □ No Pain medication: □ Yes □ No X-Rays: □ Yes □ No Anti-inflammatories: □ Yes □ No MRI: □ Yes □ No Muscle Relaxants: □ Yes □ No CT: □ Yes □ No Support/Braces: □ Yes □ No Lab work: □ Yes □ No Ice: □ Yes □ No Body parts imaged: _________________________________________________________________________

Name of medications:_______________________________________________________________________

Support/Brace location:_____________________________________________________________________ What diagnosis were you given?_____________________________________________________________

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Were you told to do anything by attending doctor? □ Yes □ No If yes, Please identify: ____________________________________________________________________________________________ Were you hospitalized at any time as a result of the injuries you sustained from the accident? □ Yes □ No If yes, Please identify the name and location of the hospital, entry date, exit date, and the name of the treating doctor(s):______________________________________________________________________ _____________________________________________________________________________________________ What was done for you at the hospital?__________________________________________________________ ____________________________________________________________________________________________ Write any Ambulance, M.D., Chiropractor, Dentist, Acupuncturist, etc., since accident. Name : Title Date seen What was done for you? Phone# __________________________ ____ ____________ _____________ ______________ __________ __________________________ ____ ____________ ___________________________ __________ __________________________ ____ ____________ _____________ ______________ __________ __________________________ ____ ____________ ___________________________ __________ __________________________ ____ ____________ ___________________________ __________ Please identify any other treatment for this injury (Check all that apply) □ Heat □Cold □Rest □Exercise □Stretches □Massage □ other________________________________

□ Slept in different position □ Slept on a different surface □ Minimized motions of the head □Minimized overhead work □Minimized lifting □Minimized sitting □ Restricted home

activities:_______________________________

□ Restricted work activities:________________________ □ Continued prescription meds:___________

□ Took over-the-counter meds:_______________________ □ other:________________________________

Normal job duties:__________________________________________________________________________ ___________________________________________________________________________________________ Current job duties:_________________________________________________________________________ __________________________________________________________________________________________ Have you missed any work and/or job opportunities as a result of your auto accident? □ Yes □ No, Please identify:__________________________________________________________________________

Have you had any injury or significant illness since the auto injury? □ Yes □ No, If yes, Please describe:__________________________________________________________________________________

Have you had any significant injury or illness, of any type, prior to the auto injury? □ Yes □ No, If yes, what was the nature of the problem and when did it occur?____________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ If professional care was rendered for the above prior injury or condition, how long were you treated, by whom, and what was done for you? Was it fully resolved?________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Have you ever had any award of permanent disability/impairment for any prior condition/injury? □ Yes □ No If yes, please identify what the award was, when it was received, and for what condition/injury: ___________________________________________________________________________________________ ___________________________________________________________________________________________

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Present Health

Please Complete Duties Under Duress and Loss of Enjoyment Worksheets What are your health concerns? ___________________________________________________ ______________________________________________________________________________ What are your goals coming in today? ______________________________________________ ______________________________________________________________________________ Please list any allergies you may have? _____________________________________________ ______________________________________________________________________________ Please list any medications you are currently taking? __________________________________ _____________________________________________________________________________ Please list any supplements you are currently taking? __________________________________ _____________________________________________________________________________ Describe your current exercise regimen? ____________________________________________ ____________________________________________________________________________________________________________________________________________________________ Before the auto accident, how would you rate your overall health? □ Excellent □ Good □ Fair □ Poor Did you have any recreational activities or hobbies before the accident? □ Yes □ No If yes, what were they and how often did you do them?___________________________________________ _____________________________________________________________________________

Medical History Have you ever been treated by a: □ Chiropractor □ Naturopathic Doctor □ Reflexologist □ Massage Therapist □ Acupuncturist □ Other alternative practitioner □ other__________________________________

Family History

Check applicable Father Mother Grandparent Sibling Other (Specify) Anemia _____ _____ _____ _____ _______ Cancer _____ _____ _____ _____ _______ Diabetes _____ _____ _____ _____ _______ Heart Disease _____ _____ _____ _____ _______ High Blood Pressure _____ _____ _____ _____ _______ Stroke _____ _____ _____ _____ _______ Epilepsy _____ _____ _____ _____ _______ Psychological Disorder _____ _____ _____ _____ _______ Asthma _____ _____ _____ _____ _______ Hay fever, Hives _____ _____ _____ _____ _______ Kidney Disease _____ _____ _____ _____ _______ Glaucoma _____ _____ _____ _____ _______ Tuberculosis _____ _____ _____ _____ _______ Age at death _____ _____ _____ _____ _______ General Health _____ _____ _____ _____ _______ (E=Excellent, G=Good, F=Fair, P=Poor)

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Habits

Smoke: □ None Pack/day:____ Years:______ Alcohol: □ Never □ Social □ Light □ Moderate □ Heavy Other:________________________________________________________________

Employment Employment: At time of crash:______________________________ □ Unemployed Currently:________________________________ □ Unemployed □ due to crash Y N Type of work: □ Office/clerical □ Light labor □ Moderate labor □ Heavy labor

Personal History As a child, did you have any of the following diseases? □ Scarlet fever □ Rheumatic fever □ Diphtheria □ Mumps □ Measles □ German measles □ Other: ______________________________________________________________________ Prior to this auto accident, have you ever been diagnosed as having any of the following? □ Whiplash □ Scoliosis □ Spondylosis □ Fibromyalgia □ TMJ Problem □ Neck Sprain □ Back Sprain □ Osteoporosis □ Pagets Disease □ Spinal Stenosis □ Spondylolysis □ Facet Arthrosis □ Disc Protrusion □ Spinal Infection □ Spondylolisthesis □ Vertebral Fracture □ Metabolic Disorder □ Diabetes Type 1 or 2 □ Any Spinal Anomaly □ Extremity Dislocation □ Rheumatoid Arthritis □ Ankylosing Spondylitis □ Foraminal Encroachment □ Carpal Tunnel Syndrome □ degenerative Disc Disease Comments:__________________________________________________________________ List hospitalizations or surgeries have you had with corresponding dates and residuals: ______________________________________________________________________________ ______________________________________________________________________________ Fractures ( dates and residuals ): __________________________________________________ ______________________________________________________________________________ Serious illness ( dates and residual ):________________________________________________ _____________________________________________________________________________ Workers’ compensation Injuries (date, TX, awards, residuals ):_________________________ _____________________________________________________________________________ Have you ever been in an auto accident? □ Yes □ No When? (dates, TX, awards, residuals ): _____________________________________________________________________________ _____________________________________________________________________________ Sport or other injuries to head, neck, or back:_________________________________________ ______________________________________________________________________________ List other injuries including falls and other traumas and when they occurred:________________ ______________________________________________________________________________ ______________________________________________________________________________ Have you been diagnosed with any diseases or disorders and when? ______________________ ______________________________________________________________________________

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Do you have any impairment or disability (date, TX, awards, residuals ): __________________ ______________________________________________________________________________ Any prior history of current complaints: 1.____________________________________________________________________________ 2.____________________________________________________________________________ 3.____________________________________________________________________________ Prior treatment by doctor of chiropractic for these complaints: 1.____________________________________________________________________________ 2.____________________________________________________________________________ 3.____________________________________________________________________________ Please provide and additional information you believe is important to your case: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Current Medical Complaints

sss=sharp or stabbing, bbb=burning, ppp=pins and needles, vvv=dull or aching, ///=numbness

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Check any and all symptoms that have appeared, even briefly, since the time of the auto collision.

□ Nausea □ Pain on swallowing □ Vertigo/dizziness/lightheadedness □ Difficulty swallowing □ Neck pain/stiffness □ Intolerance to strong odors □ Headache □ Decreased ability to smell □ Photophobia (sensitivity to light) □ Decreased ability to taste □ Phonophobia (sensitivity to load noises) □ Vision changes □ Tinnitus (ringing in the ears) ------------------------------------ □ Impaired memory □ Blood in the urine □ Difficulty concentrating □ Pain over one or both kidneys □ Impaired comprehension or awareness □ Urinary problems □ Prolong, unexplained staring ------------------------------------ □ A feeling of having a “brain fog” □ Loss of weight □ Forgetfulness □ Weight gain □ Impaired logical thinking □ Nightmares □ Difficulty with new or abstract concepts □ pain on inhaling deeply □ Insomnia (difficulty sleeping) □ Indigestion □ Fatigue □ Diarrhea □ Apathy □ Constipation □ Outburst of anger □ Vomiting □ Mood swings □ Nervousness □ Depression □ Cramping □ Loss of libido (sex drive) □ Knees bucking unexpectedly □ Personality changes □ Dropping things easily □ Intolerance to alcohol □ Weakness in the arms or legs ----------------------------------- □ Clicking in the jaw □ Popping in the jaw □ Locking of the jaw □ Side shift of the jaw upon opening □ Inability to open the mouth wide □ Pain on chewing □ Facial pain □ Grinding your teeth □ Jaw muscles sore upon waking □ Chewing on one side of your mouth □ Painful teeth □ Loose or chipped teeth □ Tender muscles in front of the neck