Chiropractic Clinic Accident Injury Form
Chiropractic Clinic Accident Injury Form
Please fill out the form below to help us understand your injury. Your information will be kept confidential and used to provide the best care for your recovery.
Patient Information
Name
Date of Birth
Phone Number
Accident Details
Date of Accident
Type of Accident
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Car
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Fall
-
Work-related
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Location of Accident
Describe your injury
Symptoms
Pain Level
Pain Location(s)
Symptoms Experienced
Check all that apply
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Headache
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Neck Pain
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Back Pain
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Numbness/Tingling
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Dizziness
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Medical History
Do you have any prior injuries to the affected area?
If yes, please describe
Are you currently seeing a healthcare provider for this injury?
Emergency Contact
Name
Relationship
Phone number
Thank you for your submission!
We appreciate you taking the time to submit.
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