Car Accident Intake Form This form is used for our car accident patients only. Our website is secured by McAfee SSL certificate. Your privacy is our #1 concern. Step 1 of 9 11% Office Location Preference*West Palm BeachPalm Beach GardensStuartPlease choose your preferred office locationName* Mr.Mrs.MissMs.Dr. Prefix First Middle Last 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 Sex*MaleFemaleDate Of Birth* Date Format: MM slash DD slash YYYY AgePlease enter a number from 0 to 100.Marital StatusSingleMarriedOtherHome Phone*Cell PhoneHow were you referred to our office?* Friend/Family Google or search engine Website Social Media Newsletter Phonebook Physician Yelp Other You may choose more than oneFriend/FamilyDo you have an attorney representing you in this accident?YesNoName of AttorneyAttorney Phone (if applies) Auto Insurance CarrierAuto Policy NumberOther Driver Carrier InsuranceClaim NumberWas the accident reported?YesNoAdjusters NameAdjusters PhoneEffective Date Date Format: MM slash DD slash YYYY OccupationEmployerEmployer Phone Do you have a primary care physician?YesNoName of Family DoctorAddress 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 Date of Last Visit Date Format: MM slash DD slash YYYY Date of Last Exam Date Format: MM slash DD slash YYYY Have you had surgery in the last 5 years?YesNoDate of last surgery Date Format: MM slash DD slash YYYY Reason for Surgery* Present Illness or Conditions*AIDSAllergiesAnemiaArthritisAsthmaBone FractureCancerCirrhosis/HepatitisDepression/AnxietyDiabetesDislocated JointsDiverticulitisEpilepsyEmotional DifficultyFrequent UrinationHay FeverHeart Burn/Acid RefluxHeart ProblemHigh Blood PressureHigh CholesterolHIV/ARCKidney/Bladder/UrinaryLeakage if Sneeze/LaughLoss of Bladder ControlLow Blood PressureMultiple SclerosisNighttime UrinationPacemakerProstate TroublePolioRheumatic FeverScoliosisSinus TroubleSpinal Disc DiseaseSTD'sThyroid TroubleTuberculosisUlcerNone of the aboveUse the CTRL key to select multiple itemsType of Cancer Breast Lung Other Other Type of CancerFamily History of Illness*AIDSAllergiesAnemiaArthritisAsthmaCancerBone FractureCirrhosis/HepatitisDiabetesDislocated JointsDiverticulitisEpilepsyHeart ProblemHIV/ARCHigh Blood PressureKidney TroubleLow Blood PressureMental IlnessMultiple SclerosisProstate TroublePolioRheumatic FeverScoliosisSpinal Disc DiseaseSTD'sSinus TroubleThyroid TroubleTuberculosisUlcerNone of the aboveUse the CRTL key to select multiple itemsType of Cancer (Family) Breast Lung Other Other Type of Cancer (Family)Do you drink alcohol?YesNoDrinks per week?Is alcohol use a concern for you or others?YesNoDo you smoke cigarettes?YesNoPacks per dayDo you use any recreational drugs?YesNoHave you ever used needles to inject drugs?YesNoDo you drink caffeine?YesNoDrinks per dayDo you exercise?YesNoRate your diet?GoodFairPoorAre you currently taking any medication either prescribed or over the counter?*YesNoWhich brand do you take?Are you currently taking any vitamins?YesNoWhich brand do you take?Do you have any known allergies?*YesNoList Allergies* Date of Accident* Date Format: DD slash MM slash YYYY Time of Accident : HH MM AM PM Were you the driver or passenger?*DriverPassengerIn you own words, describe how the accident happened*Did you wear your seatbelt?*YesNoDid you brace before the impact?*YesNoI braced with...* My hands My feet Other What did you brace with?*Did you strike anyting within your vehicle at the time of impact?*YesNoNot SureWhat did you strike?*Did the seatback break?*YesNoImmediately following the accident, how did you feel?* Dizzy/Dazed Disoriented Confused I felt Fine Nervous Nauseous Upset Weak Shaken Up Describe any cuts or bruisesWhat are your symptoms related to the accident?* Arm Pain Left Arm Pain Right Hands Headaches I felt Fine Legs Low Back Pain Mid Back Pain Neck Pain Shoulder Pain Left Shoulder Pain Right Toes Were you knocked unconscious?*YesNoApprox how long (in minutes)? Did you go to the hospital or urgent care facility?*YesNoWhich hospital or clinic?*When did you go to the hospital or clinic?* Date Format: MM slash DD slash YYYY How did you get to the hospital or clinic?AmbulanceDrove myselfSomeone else drove meWho drove you?Were Xrays taken?*YesNoWhat parts?*List any other doctors you have seen as a result of this accident.DateDoctor Additional Neurological Symptoms Blurred Vision Dizziness Double vision Headaches Light headed Loss of Balance Memory Loss No Symptoms Numbness Ringing in the ears Sensitivity to light Tingling TMJ/Jaw Symptoms Have you been involved in a previous motor vehicle accident?YesNoPlease describe the previous accidentDid you have any physical complaints before this accident?*YesNoPlease describe the previous complaints Have you missed work?YesNoDates of lossHave you returned to work?*YesNoList any restrictions placed on yourselfWhat activities, if any, aggravate your condition at workAre you pregnant?YesNoLast menstrual cycle Date Format: MM slash DD slash YYYY Upload Accident Information Drop files here or Accepted file types: jpg, pdf, doc, dox. Please upload any accident information such as insurance documents and policy documents.NameThis field is for validation purposes and should be left unchanged.
