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 Beach Palm Beach Gardens Stuart Lake Worth Please 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* Male Female Date Of Birth* 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/Family Do you have an attorney representing you in this accident?YesNoName of Attorney Attorney Phone (if applies) Auto Insurance Carrier Auto Policy Number Other Driver Carrier Insurance Claim Number Was the accident reported? Yes No Adjusters Name Adjusters PhoneEffective Date MM slash DD slash YYYY Occupation Employer Employer Phone Do you have a primary care physician? Yes No Name of Family Doctor 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 Date of Last Visit MM slash DD slash YYYY Date of Last Exam MM slash DD slash YYYY Have you had surgery in the last 5 years? Yes No Date of last surgery 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 Cancer Family 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? Yes No Drinks per week?Is alcohol use a concern for you or others? Yes No Do you smoke cigarettes? Yes No Packs per dayDo you use any recreational drugs? Yes No Have you ever used needles to inject drugs? Yes No Do you drink caffeine? Yes No Drinks per dayDo you exercise? Yes No Rate your diet? Good Fair Poor Are you currently taking any medication either prescribed or over the counter?* Yes No Which brand do you take?Are you currently taking any vitamins? Yes No Which brand do you take?Do you have any known allergies?* Yes No List Allergies* Date of Accident* DD slash MM slash YYYY Time of Accident : Hours Minutes AM PM Were you the driver or passenger?* Driver Passenger In you own words, describe how the accident happened*Did you wear your seatbelt?* Yes No Did you brace before the impact?* Yes No I braced with...* My hands My feet Other What did you brace with?* Did you strike anyting within your vehicle at the time of impact?* Yes No Not Sure What did you strike?* Did the seatback break?* Yes No Immediately 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?* Yes No Approx how long (in minutes)? Did you go to the hospital or urgent care facility?* Yes No Which hospital or clinic?* When did you go to the hospital or clinic?* MM slash DD slash YYYY How did you get to the hospital or clinic? Ambulance Drove myself Someone else drove me Who drove you? Were Xrays taken?* Yes No What 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? Yes No Please describe the previous accidentDid you have any physical complaints before this accident?* Yes No Please describe the previous complaints Have you missed work? Yes No Dates of loss Have you returned to work?* Yes No List any restrictions placed on yourselfWhat activities, if any, aggravate your condition at workAre you pregnant? Yes No Last menstrual cycle MM slash DD slash YYYY Upload Accident Information Drop files here or Select files Accepted file types: jpg, pdf, doc, dox, Max. file size: 1 GB. Please upload any accident information such as insurance documents and policy documents.EmailThis field is for validation purposes and should be left unchanged.
