Skip to main content
Skip to footer

Fakhoury Medical & Chiropractic Center

Ocala Chiropractor

Home
Patient Intake
About
Appointments v1
- Active Patient
- New Patient
Testimonials
Conditions
Resources
- Veterans
Blog
Contact

Car Accident? Pain?

Auto Accident Intake Form

Auto Accident Intake Form

Step 1 of 11

9%

Name*
Prefix First Middle Last Suffix
Email*
Enter Email Confirm Email
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Work Phone
Cell Phone
Sex*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Age
Marital Status
Ethnicity
Other Ethnicity
Emergency Contact + Phone Number
Enter your emergency contact with phone number
Who 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 condition
Are the symptoms:
- Improving
- Getting Worse
- About the Same
- Intermittent (come & go)

What is your chief 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 take
Do you have any known allergies?*
- Yes
- No
List Allergies
Past Medical History (Ctrl Key to select multiple)
List 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)
Select all that apply
List Other
Do 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 Phone
Florida PIP Law Notification
Please 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.

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

Accepted file types: pdf, jpg, png, Max. file size: 100 MB, Max. files: 3.
Signature Requirement
I 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
Full Legal Name
Date
MM slash DD slash YYYY
Signature*

Footer

Find Us!

Hours of Operation

Our Office Hours Are As Follows:

Monday 7:30 to 6:00
Tuesday 7:30 to 6:00
Wednesday 7:30 to noon
Thursday 7:30 to 6:00
Friday 7:30 to 6:00

Contact Us

Phone: (352) 351-3413
Fax: (352) 629-6667
Address:1009 SW 16th Lane

Ocala, FL 34471

Copyright 2015 ·

[aps-social id="1"]

· designed by iWebResults - Sitemap

Font Resize

Contrast

Accessibility by WAH