Auto Accident Intake Form Auto Accident Intake Form Step 1 of 11 9% Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Email* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneCell PhoneSex* Male Female Date of Birth* MM slash DD slash YYYY AgeMarital StatusSingleMarriedDivorcedWidowedEthnicityWhiteAfrican AmericanHispanic/LatinoAsianOtherDecline to answerOther Ethnicity Emergency Contact + Phone Number Enter your emergency contact with phone numberWho is your employer + position Which of the following activities aggravate your condition: (Select all that apply)* Bending Coughing Lifting Lying Down Sexual Activity Sitting Sleeping Sneezing Standing Twisting Walking Other Other activities* Please list other activities that aggravate your conditionAre the symptoms: Improving Getting Worse About the Same Intermittent (come & go) What is your cheif complaint?* Is this condition due to:* Auto Accident Work Related Fall Other Please list other* Do you take medication?* Yes No List medications you currently takeDo you have any known allergies?* Yes No List AllergiesPast Medical History (Ctrl Key to select multiple)AsthmaBladder DisorderBowel DisorderBronchitisDepressionDiabetesHeart DiseaseHigh Blood PressureKidney DiseaseLung DiseaseMental IllnessPolioRheumatismSeizureStrokeThyroidTuberculosisUlcerOtherNoneList Other* Have you ever had surgery?* Yes No List your surgery* Do you have a family history with any of the following? (Ctrl Key to select Multiple)ArthritisBack ProblemsCancerDiabetesHeart AttacksHypertensionTuberculosisOtherNoneSelect all that applyList OtherDo you smoke? Yes No Packs per week Do you drink alcohol? Yes No Drinks per week Do you drink caffeine? Yes No Drinks per day Do you exercise? Yes No How many times per week? Do you use any recreational drugs? Yes No How many times per week? Has your pain interfered with your normal work inside & outside the home? On a scale 0 (No change) to 10 (Unable to work at all) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (Unable to work at all)Has your pain interfered with personal care (washing, dressing, etc.)? On a scale 0 (No change) to 10 (Need help with care) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (Need help with care)Has your pain interfered with your traveling? On a scale 0 (No change) to 10 (Only to see doctors) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (Only to see doctors)Has your pain interfered with your ability to sit or stand? On a scale 0 (No change) to 10 (Cannot sit/stand at all) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (Cannot sit/stand at all)Has your pain interfered with your ability to lift overheard, grasp objects, or reach for things? On a scale 0 (No change) to 10 (Cannot do at all) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (Cannot do at all) Has your pain interfered with your ability to lift objects off the floor, bend, stoop, or squat? On a scale 0 (No change) to 10 (Cannot do at all) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (Cannot do at all)Has your pain interfered with your ability to walk or run? On a scale 0 (No change) to 10 (Cannot walk/run at all) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (Cannot walk/run at all)Has your income declined since your pain began? On a scale 0 (No change) to 10 (Lost all income) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (Lost all income)Do you take medication every day to control your pain? On a scale 0 (No change) to 10 (On pain medication throughout the day) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (On pain medication throughout the day) Has your pain forced you to see doctors much more often than before your pain began? On a scale 0 (No change) to 10 (See doctors weekly) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (See doctors weekly)Has your pain interfered with your ability to see the people who are important to you? On a scale 0 (No change) to 10 (Never see them) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (Never see them)Has your pain interfered with recreational activites and hobbies that are important to you? On a scale 0 (No change) to 10 (Total interference) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (Total interference)Have you needed the help of family and friends to complete everday tasks (at home & work) because of pain? On a scale 0 (No change) to 10 (Need help all the time) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (Need help all the time)Have you felt more depressed, tense, or anxious than before your pain began? On a scale 0 (No change) to 10 (Severe depression/tension) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (Severe depression/tension)Are there emotional problems caused by your pain that interfere with family, social or work related activites? On a scale 0 (No change) to 10 (Severe Problems) 0 (no change) 1 2 3 4 5 6 7 8 9 10 On a scale 0 (No change) to 10 (Severe Problems) What type of accident was this? Auto Motorcycle Pedestrian Did you go to the hospital or urgent care facility? Yes No Which hospital or clinic? When did you get treatment? MM slash DD slash YYYY Were Xrays, MRI's or CT Scans taken? Yes No Which Parts? Was the accident your fault? Yes No Other Were there any passengers in the car? Yes No Who receieved a citation/ticket? Myself Other Driver None Given What area of the body do you feel pain? Arm Pain Left Arm Pain Right Hands Headaches Legs Low Back Pain Mid Back Pain Neck Pain Shoulder Pain Left Shoulder Pain Right Toes Date of Accident MM slash DD slash YYYY Did you report your injuries to your insurance company?* Yes No Insurance Carrier* Policy Number Claim Number* Adjusters Name Adjusters PhoneFlorida PIP Law NotificationPlease remember that you have 14 days from the time of your accident to file a claim if you want PIP benefits. Contact your insurance company so they are aware you will be receiving treatment. How were you referred to our office? Friend/Family Google or search engine Billboard Physician Website Self Other Friend/Family* Have you obtained or consulted with an attorney? Yes No Attorney Name Attorney Phone File Upload - Please include a copy of your drivers license and auto insurance card. Drop files here or Select files Accepted file types: pdf, jpg, png, Max. file size: 128 MB, Max. files: 3. Signature RequirementI clearly understand that if I am accepted as a patient at Fakhoury Medical and Chiropractic Center, I authorize them to proceed with the treatment as necessary. Any risks regarding such treatment will be explained upon request. I also understand and agree that all services rendered to me are charged directly to me and I am personally responsible for payment. In the case insurance verification is obtained, insurance claims may be filed. I understand that the filing of insurance is not a guarantee of payment, and I remain responsible for the entire amount due. I also understand that if I terminate my care and treatment, any fees for professional services rendered me prior to my termination of care will be immediately due and payable. In the extend of default, I promise to pay legal interest on the indebtedness together with such collection costs and reasonable attorney fees as may be required to effect collection. I hereby attest that the above and all following information is true to the best of my knowledge.* I agree Signature*
