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Auto Accident Health History
Please complete our initial health history form so that we can better serve you in our office.
(Note: Please type N/A in sections that don't apply). It is important to note that we may contact you, if necessary, regarding areas are not completed fully, in order to you with the best care possible.
NEW PATIENTS ONLY: If you do not receive a follow-up email within 24 business hours, please contact our office to confirm we have received your Health History Form.
Thank you.
(215) 504-2711
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* Indicates required question
Email
*
Your email
Patient's Full Name: (First, Middle, Last,)
*
Your answer
Date of Birth:
*
Your answer
Age:
*
Your answer
Gender:
Choose
Female
Male
Address:
*
Your answer
City:
*
Your answer
State:
*
Your answer
Zip Code:
*
Your answer
Phone number (best contact):
*
Your answer
Occupation:
*
Your answer
Date of Auto Accident:
*
MM
/
DD
/
YYYY
State Auto Accident Occurred:
*
Pennsylvania
New Jersey
Other:
Was a police report made?
*
Yes
No
Other:
Auto Insurance Company Name:
*
Your answer
Auto Insurance Adjusters Name:
*
Your answer
Auto Insurance Adjusters Phone Number:
*
Your answer
Auto Insurance Case-Claim Number:
*
Your answer
Auto Insurance Companies Address:
Your answer
Attorney's Name:
Your answer
Attorney's contact information (Address, Phone):
Your answer
Primary Health Insurance Company Name:
*
Your answer
Primary Insurance - Policy ID:
*
Your answer
Primary Insurance - Policy Group Number:
*
Your answer
Martial Status:
Choose
Single
Married
Separated
Divorced
Widowed
Domestic Union
Primary Insurance Policy Holder's Name:
*
Your answer
Insurance Policy Holder's Date of Birth:
*
Your answer
Whom may we thank for referring you?
Your answer
Have you seen a Medical Doctor for this current condition?
Yes
No
Clear selection
Have you seen a Chiropractor before (yes)? What for?
Your answer
Diagnostic Test Performed
If you have had any diagnostic testing performed for your current condition, please bring any and all images, reports, CDs or any information to your appointment.
Diagnostic Testing Performed?
XRAYS
MRI
CAT SCAN
Blood Work
Clear selection
(Medical History) Have you ever suffered from:
*
Dizziness
Backaches
Diabetes
Heart Trouble
High Blood Pressure
Headaches
Asthma
Stomach Trouble
Sinus Trouble
Arthritis
Liver Problems
Bowel Issues
Fractures
Cancer
Reproductive Issues
Allergies
History of Smoking
None
Other:
Required
Explain Medical history from previous question? (List fractures, surgeries, heart, lung, reproductive issues, cancer, diabetes, high blood pressure, arthritis, N/A, etc.)
Your answer
Have you ever been in or have had any of the following traumas?
Auto Accident (s)
Motorcycle Accident (s)
Fall Down Stairs
Slip on Ice
Fallen off a Horse or Bicycle
Falls of any kind not mentioned
Sports Injuries
Work Injuries
Lifting Injuries
Other:
Please list all medications and/or supplements currently taking:
Your answer
Have you tested positive for Coronavirus?
*
Yes
No
Required
Have you had a temperature above 100.4 F within the pat 2 weeks? (If "Yes" please explain)
*
Your answer
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