CHARLOTTE-Salama-Chiropractic-New-Patient-AUTO-ACCIDENT-INJURY-Form-2-27-2019

Auto Accident Injury Questionaire

Salama Chiropractic Center

APPOINTMENT INFORMATION

Select your appointment location

Greensboro - 3410 West Wendover Aveue, Suite A Greensboro - 2608-A Lawndale Drive Oak Ridge - 1692 NC Highway. 68, Suite E Winston-Salem - 1515 Hanes Mall Boulevard Charlotte - 2200 Randolph Road

PATIENT INFORMATION

Patient Full Name (First, Middle & Last Names)

Your Email Address

Date of Birth

Date

1. What was the date of the accident?

2. What time of day did the accident occur?

3. How many vehicles were involved in the accident?

4. What was the estimated damage (in dollars) to the vehicle you were in?

5. What city did the accident occur in?

6. What state did the accident occur in?

7. What type of impact was the auto accident?

Rear Ended Hit On Driver’s Side Hit Another Vehicle From Behind Hit On Passenger Side

8. Did your vehicle hit anything after the accident? If yes, please describe.

9. Where were you sitting in the vehicle during the accident?

Driver’s Seat Rear Left Passenger Front Passenger Rear Right Passenger

10. Did you know the accident was coming?

Unaware Of Impending Collision Aware Of Impending Collision Aware Of Impending Collision And I Braked

11. What type of vehicle were you in?

If you selected “Other” please describe it.

12. What type of vehicle impacted yours?

If you selected “Other” please describe it.

13. At the time of the impact, how fast was your vehicle moving?

Slowing Down Stopped Gaining Speed Moving Steady Speed

14. Did you lose consciousness during the accident?

Yes No

15. Did you have your seatbelt on during the accident?

Yes No

16. Did you go to the hospital?

Yes No

If no, why? And skip questions 17-22.

17. How did get to the hospital?

18. What is the name of the hospital?

19. Were you hospitalized overnight?

Yes No

20. Check what you were prescribed at the hospital

If "Other” What were you prescribed?

21. Did you receive any stitches for any cuts at the hospital?

Yes No

22. Were x-rays taken at the hospital?

Yes No

If yes, which area was taken?

Other

****If X-rays were taken at the hospital, you will need to pick up a copy of these X-rays from the hospital records department and bring them with you to your first appointment so we do not have to re-take any X-rays.****

Please print name of Patient, Parent, Guardian or Personal Representative

Date

Relationship to Patient