Name: Palm Beach Chiropractic & Rehabilitation, Inc.
Price range: $$

Welcome to Palm Beach Chiropractic & Rehabilitation.

Please carefully complete the following health questionnaire.

Patient Name

Todays Date

Date of birth

Age

Sex

Street Address

Unit/Apt number

City

State

Zip code

Email

Phone

Height

Weight

Marital Status

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Emergency Contact Info

Name

Relationship

Contact Phone

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Complaint 1

What's bothering you?

Please provide additional information

When did the pain start?

How did the injury occur?

Frequency of Pain

Quality of Discomfort

Aching

Dull

Sharp

Throbbing

Stiffness

Numbness / Tingling

How severe is the pain?

scale from 1-10 (10 being the worst)

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Add Another Complaint

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Auto accident

Is your visit related to an auto accident?

Yes

No

Motor Vehicle Accident Health History

Who is YOUR auto insurance carrier

Auto insurance policy number

Date of Accident

Claim #

Year of YOUR vehicle

Make and Model

Where were you seated in the vehicle?

Were you wearing a seat belt?

Where were you looking at the time of impact?

Where was your vehicle impacted?

Which direction was YOUR vehicle moving at the time of impact?

Which direction was the OTHER vehicle moving at the time of impact?

The Accident

Was your vehicle towed from the scene?

Did the Police arrive at the scene?

Was an accident report filed?

Please briefly describe the accident in your words.

Did EMS arrive at the scene?

Did YOU go the ER or Urgent Care?

Mode of Transport? and What care did you receive?

Medical History

Have you been involved in past motor vehicle accidents?

When and where did the accident occur?

What type of care did you receive?

What injuries were you treated for?

Did all of your symptoms resolve from the previous accident?

Please explain what remains.

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.

Patient Signature

Todays date

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Insurance Information

Please enter your information as shown on your insurance card.

Insurance or Self Pay?

Policy Holders Name

Patient Relationship to Policy Holder

Health Insurance Provider

Member ID Number

Group number

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Personal Health History

Medications / Supplements? If you are currently taking any, please list them.

Have you seen anyone else for this condition?

List all operations and surgeries you may have had, with dates (month/year):

List any major illness you have had, with dates (month/year)

Please list any and all traumas or injuries you’ve ever had, with dates, (this includes any past auto accidents)

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Social History

Tobacco

Alcohol

Caffeine

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Review of Systems & Medical History

Please mark any of the following conditions that apply to you, past or present

AIDS/HIV

Anemia

Arthritis

Asthma

Bleeding Disorders

Bronchitis

Cancer

Diabetes

Epilepsy

Fractures

Gout

Glaucoma

Heart Disease

Hepatitis

Online intake form

Thank. See you soon at your scheduled appointment!

Welcome to Palm Beach Chiropractic & Rehabilitation.

Emergency Contact Info

Complaint 1

Auto accident

Motor Vehicle Accident Health History

The Accident

Medical History

Insurance Information

Personal Health History

Social History

Review of Systems & Medical History