AUTO ACCIDENT QUESTIONNAIRE
Name:
Age:
Today’s Date:
Date of Accident:
Location of accident:
Part of car that was damaged:
Approx. $ Damage
Part of other car that was damaged:
Approx. $ Damage
Were you hit on the:
Front
Rear
Left side
Right side other:
Type of car you were in:
other car type:
Speed you were traveling:
mph
Speed of other vehicle:
mph Were you:
Driver/passenger in front seat
Back seat
Was Road:
Dry
Wet
Icy
Snow other:
No
Yes lightly
Yes Heavily
Was the driver’s foot on the brake when hit?
Don’t know
Yes
No
Lap belt only (no shoulder harness)
Were you wearing a safety belt?
Straight ahead
Right
Left
Up
Down
Was your head facing (when accident occurred)?
None
Below level of my ear
Between ear and top of head
Above the head
How high was the headrest?
Yes
No
Did you see the other car before impact?
Yes
No
Did you hit your head or bruise any part of your body?
Yes
No other items moved in vehicle:
Were your glasses knocked off?
Yes
No
Was an ambulance used for you?
Did you lose consciousness in the accident?
TREATMENT HISTORY DATE
PLEASE LIST ALL FORMS OF THERAPY AND PROFESSIONALS SEEN INCLUDE HOSPITALS
PROFESSION
TESTS
DIAGNOSIS
Do you have automobile insurance that covers medical expenses (MED PAY)?
TREATMENT
Yes
No
(If no, there must be a lien in place or the patient can use private health care ins.)
Private Health Insurance?
Yes
No (if yes, we need copy of insurance card. Patient must pay co pays, deductible and percents at time of visit)
If plan to use health insurance, you must ask the insurance co. for a suborgation/repayment agreement that most times is required that you
sign.
Do you have an Attorney?
Yes
No
Attorney Name:
Phone #
Address:
Insurance co.:
Adjuster:
Employer:
Phone #
Address:
Work #
Occupation
Did you lose time from work due to accident?
Please select the correct answer:
regular duty
How much?
light duty
part time
Year employed
Are you working now
full time
Hours per week before and after accident
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand
that this office will prepare any necessary reports and forms to assist me in making collections from the insurance company and third parties and that any
amount authorized to be paid directly to this office will be credited to my account on receipt. I also give this office power of attorney to endorse checks made
out to me, to be credited to my account. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am
responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be
immediately due and payable. AUTHORIZATION AND ASSIGNMENT: I authorize Fernley Chiropractic to release any information to insurance co.,
attorneys, or other physicians, who may request this information. I also assign payments from my insurance company for services rendered at this office to be
paid directly to Fernley Chiropractic.
PATIENT’S SIGNATURE:
DATE: