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Welcome to Palm Beach Chiropractic & Rehabilitation.
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Complaint 1
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Auto accident
Yes
No
Motor Vehicle Accident Health History
The Accident
Medical History
Thank you for taking the time to fill out this accident questionnaire. This information is important in the doctor obtaining a clinical
picture so as to make an appropriate diagnosis and treatment plan. Please sign below authorizing that the information in this
form has been read and filled out completely and accurately to the best of your understanding. Also, understand that the
information in this form is considered confidential and for use by your doctor at Palm Beach Chiropractic and Rehabilitation, Inc.
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Insurance Information
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Review of Systems & Medical History
Please mark any of the following conditions that apply to you, past or present