AUTO ACCIDENT INITIAL HISTORY FORM
Name: Date:
Address: __________________________________City:__________________State:________Zip:_______
Home Phone:_____/_____/_______ Work:_____/_____/_______ ext:_______ Cell:_____/_____/_______
E-Mail address (for emergencies and newsletters only)___________________________________________
Date of Birth:________/________/_______Age:____________Height: ft. in. Weight:
Marital Status: M S W D Name of Spouse:
Children? Y N Names/Ages of Children:
Employer: Occupation:_______________________________
Emergency Contact Person: Relation:____________________________ Address: City:______________State:__________Zip:________ Phone:_______/_______/_______ Who referred you here? ___________________________________
ACCIDENT HISTORY
Date of Accident ____/_____/_____ Time of Accident _____ o AM o PM Where?______________________________
Details of the Accident ______________________________________________________________________________
_________________________________________________________________________________________________
Make/Model/Year of your Vehicle________________________ Make/Model/Year other vehicle____________________
Driver or Passenger? _______ oLap belt oShoulder Belt oBoth oNo Seat Belt Worn Passengers? Y N Number___
How far is the top of the headrest from the top of your head? Approximately______inches oAbove oBelow o Not Sure
How far away is the headrest from the back of your head? Approximately ______inches away o Not Sure
Were police at the accident scene? oYes oNo Is there an accident report? oYes oNo Road: oWet oDry oIcy Did you go to the hospital? o Yes o No By ambulance? o Yes o No
List exams and tests you received at the hospital _________________________________________________________
_________________________________________________________________________________________________
Diagnosis, home treatment, medication by hospital? ______________________________________________________
Were you oAware of the approaching collision prior to impact, or did it oCatch you totally by surprise?
Any cuts or bruises from this accident? __________________________________________________________________
Did you lose consciousness (black out) upon impact? oYes oNo How long were you out? ______________________
Did you experience a flash of light/explosion in your head, or ”see stars”? oYes oNo
Was your vehicle stopped at the time of impact? oYes oNo Was your vehicle oSlowing down oGaining speed oTraveling at a steady rate Was your foot on the brake? oYes oNo
oAutomatic transmission oStandard transmission Was the car in gear? oYes oNo
Was the other vehicle stopped at the time of the accident? oYes oNo
Was this vehicle oSlowing down oGaining speed oTraveling at a steady rate
Was the trunk of your body pointed straight forward at the time of collision? oYes oNo
If no, what direction was it turned? _____________________________________________________________________
Was your head pointed straight forward at the time of collision? oYes oNo
If no, what direction was it turned? _____________________________________________________________________
Did any body parts strike something in the car? __________________________________________________________
What parts of the vehicle broke? oWindshield oFront Seat Back oSteering Wheel oOther____________________
What is the estimated cost of damage to your vehicle?_____________________________________________________
Please list the symptoms caused by this accident.
1. ____________________________________________________________________________________
2. ____________________________________________________________________________________
3. ____________________________________________________________________________________
4. ____________________________________________________________________________________
5. ____________________________________________________________________________________
6. ____________________________________________________________________________________
7. ____________________________________________________________________________________
8. ____________________________________________________________________________________
9. ____________________________________________________________________________________
10. ___________________________________________________________________________________
Overall, at this time, is your condition: o Becoming worse o Remaining the same oImproving
Please list other doctors or health care practitioners you have seen for this accident.
1. _______________________________________________________________________________________________
2. _______________________________________________________________________________________________
3. _______________________________________________________________________________________________
Are you currently taking any prescription drugs or over the counter drugs? o Yes o No (List Below)
_________________________________________________________________________________________________
Are you currently taking any vitamins or supplements? o Yes o No (List Below)
_________________________________________________________________________________________________
Have you stopped or changed your exercise program due to your accident? o Yes oNo
If so, what modifications have been made? ______________________________________________________________
What else are your problems preventing you from doing? Sports _______________ Hobbies _____________________
Family/Kids ____________________ Work ____________________ Other ____________________
Before this accident, were you suffering from any of the symptoms above? o Yes o No (If yes, please explain)
_______________________________________________________________________________________________
Prior to this accident, have you been involved in any similar types of injuries? o Yes o No (List Below)
If yes, when Did you recover? Any residual symptoms?
_________________________________________________________________________________________________
WORK HISTORY
At the time of this injury did you have a job? o Yes o No
Employer/Address _________________________________ Occupation
Did you miss any work because of your injuries? o Yes o No From:____/____/____ To:____/____/____
Returned to work on: ______/______/______ Light or Full Duty? ___________________________________________
Did you lose your job because of your injuries? oYes o No Did you change jobs because of your injuries? o Yes o No
Explain your job requirements, including positions and postures: ____________________________________________
Have you seen any other chiropractors? Y N Name:____________________________________________________
Location:__________________ Reason/diagnosis: ____________________________________________________
Any surgeries in your past? (include dates)_______________________________________________________________
_________________________________________________________________________________________________
Who is your primary physician? Name: ________________________________ Location: _____________
When is the last time you visited your physician? Date:______________ Reason: _______________________________
Have you ever smoked? Y N Do you smoke now? Y N
If yes, how long, how much, and when did you quit? ______________________________________________________
Please list previous accidents/injuries, including major childhood traumas with dates and hospitalizations.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What childhood illnesses have you had (measles, chicken pox, etc.)? ____ Usual Other __________________________
FAMILY HISTORY
Do any of your blood family have, or had, any of the following?
PROBLEM YES NO PROBLEM YES NO
Chronic Back/Neck Pain o o Stroke o o
Surgery o o Heart Problems o o
Scoliosis o o High Blood Pressure o o
Diabetes o o Arthritis o o
Other ____________________________________________________________________________________________
Have you ever suffered a stroke, heart attack, or vascular disease? o Yes o No
Has anyone in your family suffered a stroke, heart attack, or vascular disease? o Yes o No (List Below)
_________________________________________________________________________________________________
Females: Do you take birth control pills? oYes oNo When did you start?______________
Have you ever taken birth control pills in the past? o Yes o No If yes, for how long (dates)?_____________________
Check any of the following conditions you have had or do have:
__ Allergies __ Eczema __ Neck Pain
__ Sinus Problems __ Other Skin Problems __ Mid Back Pain
__ Asthma __ Headaches __ Low Back Pain
__ Anemia __ Migraines __ Shoulder Pain L R
__ Arthritis __ Heart Disease __ Elbow Pain L R
__ Cancer __ Heart Attack __ Hand Pain L R
__ Depression __ Menstrual Problems __ Hip Pain L R
__ Diabetes __ Multiple Sclerosis __ Leg Pain L R
__ Digestive Problems __ Stroke __ Knee Pain L R
__ Drug Abuse/Addiction __ Weight Problems __ Foot Pain L R
__ Alcoholism __ Ringing in Ears __ Carpal Tunnel L R
__ Stress __ Dizzy/Balance Problems __ (Other)___________________
__ High Blood Pressure
o Yes oNo Any personality/emotional changes? If so, what? ___________________________________
o Yes oNo Have you lost any sense of smell, or are you more sensitive to odors?
o Yes oNo Do you see spots or any disturbances or changes to your vision?
oYes oNo Do your eyes and/or mouth get dry?
o Yes oNo Does your heart feel like it races?
o Yes oNo Do you break a sweat easy?
o Yes oNo Do you sweat more on one side of the body than the other?
o Yes oNo Have you noticed any changes in your bowel or bladder function? If so, what? _____________
__________________________________________________________________________
o Yes oNo Any changes in sexual function? If so, what? _______________________________________
o Yes oNo Have you noticed any short or long-term memory changes?
o Yes oNo Are you fatigued?
o Yes oNo Do you have any muscle twitches?
o Yes oNo Do you consume caffeine (coffee, soda, tea)? If so, how much? _______________________
o Yes oNo Do you choke on foods or liquids?
How old are your parents and what is their state of health? _________________________________________________
If deceased, cause of death: _________________________________________________________________________
Siblings, ages, and health: ___________________________________________________________________________
CONSENT TO TREATMENT AUTHORIZATION
By my signature below, I certify that the above information is correct. I authorize Fuller Chiropractic, P.C. to perform an examination, take x-rays if necessary, and administer chiropractic treatment. I authorize Fuller Chiropractic to contact other health care providers I have to coordinate my care, and to release information to my other providers for coordination of care, and to release my health information for insurance reimbursement purposes.
_____________________________________ _______/_______/_______
Patient Signature Date
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