WELCOME TO
Today’s Date: ___________________
Patient’s Name:___________________________________
Patient’s Address: __________________________________ City____________________________
Patient’s S.S. #: __________________ Patient’s Date of Birth: ____________________________
Sex: M
F
Marital Status: M
D
S
W
Spouse’s Name:_______________________
Children: Ages:_______________________
Phone Number: Home: ____________________ Cell: ___________________
Work:___________________ Email: _______________________________________________
Habits
Smoke:
None
Pk/day_________Years _________ Alcohol:
Never
Social
Light
Mod
Heavy
Employment
Occupation: __________________________
Employer: ___________________________________
Employer Address: __________________________________________________________________
Employer Phone #: ___________________________
Emergency Contact
Name: ___________________ Relationship: __________________ Phone: _______________________
Past Medical History
Surgeries: ______________________________________________________________________________
Fractures: ______________________________________________________________________________
Serious Illness: __________________________________________________________________________
Prior History of Complaints: ________________________________________________________________
Prior Treatment by Doctor for these: _________________________________________________________
Current Medical History
Current Health Problems:
None ______________________________________________________
Current Medications Taken: None _______________________________________________________
Are You Pregnant?
No
Yes Due Date: _________________________________________
Injury History
Date of Accident/Injury:_______________________Was the crash on the job?
No
Yes
Your Vehicle: Year: _______________ Make: ___________________ Model: ________________________
Vehicle Driven By? __________________________ Where were you seated? _______________________
Estimated Speed at moment of Crash: ______________MPH
Stopped
Slowing
Accelerating
Did Air Bags Deploy?
Yes
No
Other Vehicle: Year: _______________ Make: ___________________ Model: _____________________
Street Accident Occurred On:_______________________ Intersecting Street: ______________________
Aware Of Impending Crash?
Yes
No
5931 South University Drive, Davie, Florida 33328 Tel. 954.252.3339 Fax. 954-252-3315
[email protected] www.SFMWC.com
WELCOME TO
Crash Diagram:
During the Crash
Did you strike any part of the vehicle?
Yes
No If yes describe: ______________________________
Did the vehicle strike any objects after crash? Yes
No If yes describe: _________________________
Did you lose consciousness? Yes
No
Estimate damage to your vehicle: None
Minimal
Moderate
Major
Were police on the scene? Yes
No
Was a report made? Yes
No
After The Crash
Symptoms: Headaches
Dizziness
Nausea
Neck Pain
Mid Back Pain Low Back Pain
Extremity Pain
When did symptoms first appear? Immediately Later If later how
long?_________________________________
Pain is: Constant Comes and Goes
Mark Areas of Pain as Follows: A-Aches B-Burning N-Numbing P-Pins and Needles S-Stabbing O-Other
Rate Severity of Pain 1(least pain)-10 (most pain) ___________________
Where did you go after the crash? Home Work Hospital Name of Hospital______________________
Emergency Department
Radiographs: Yes No Body parts imaged: _______________________________________________
Other Imaging: ________________________
Medications: ________________________________________________________________________
5931 South University Drive, Davie, Florida 33328 Tel. 954.252.3339 Fax. 954-252-3315
[email protected] www.SFMWC.com