Auto Accident History Form

In order to provide you with the best possible care, please complete this form in detail as well as the “New Patient History” and "New Patient Signatures" forms.

Auto Accident History

Name*
First Last
Date of Scheduled Appointment
MM slash DD slash YYYY
Date of Accident*
MM slash DD slash YYYY
Were you the
- Driver
- Front Passenger
- Rear Passenger
If a traffic violation was issued, to who was it issued?
Number of people in accident vehicle?
Did the police come to the accident site?
Was a police report filed?
Were there any witnesses?
Were you wearing
Was this vehicle equipped with airbags?
If yes, did they inflate?
In relation to the base of your skull, where was the headrest?
Did your vehicle impact?
If other, explain
Did any part of your body strike anything else in the vehicle?
If yes, explain
Make and model of the vehicle you were occupying?
Name of the location/street on which you were traveling?
In which direction were you heading?
What was the approximate speed of your vehicle?
Please answer in MPH.
Did the impact to your vehicle come from the
During the impact, were you facing
Were you
Make and model of other vehicle involved?
Direction other vehicle was heading?
Speed of other vehicle?
Please answer in MPH.
In your words, please describe the accident
After Injury
Did the accident render you unconscious?
If yes, for how long?
Please describe how you felt immediately after the accident
Did you go to a hospital or see any other doctor?
When did you go?
How did you get there?
Name of Hospital and/or Attending Doctor
Was he/she a
Describe any treatments you received
Were X-rays taken?
Were medications prescribed?
Have you been able to work since this injury?
Have your work activities been restricted as a result of this injury?
Please check the symptoms that are a result of this accident
- Neck Pain
- Tight/Sore Muscles
- Upper-Back Pain
- Mid-Back Pain
- Lower-Back Pain
- Headaches
- Sciatica
- Joint Problems
- Memory Loss
- Digestive Problem
- Leg and Hip Problems
- Dizziness
- Carpal Tunnel Syndrome
- Difficulty Breathing
- Stiffness
- TMJ Problems
- Tingling or Numbness
- Blurred Vision
Is your condition getting worse?
Are your symptoms
Indicate your degree of comfort while performing the following activities
Lying on Back
Lying on Side
Sitting
Standing
Stretching
Walking
Running
Sports
Working
Lifting
Bending
Kneeling
Pulling
Reaching
Recovery
To evaluate the effect that continuing to work will have on your recovery please complete the following.
How many hours are in your normal work day?
Please indicate your daily job duties and any activities which you are occasionally asked to perform
- Standing
- Sitting
- Walking
- Lifting
- Driving
- Twisting
- Crawling
- Bending
- Operating Equipment
- Work with arms above head
- Typing
- Stooping
- Other
If you selected other above, please list here
Prior to the injury, were you capable of working on an equal basis with others your age?
Do you work with others who can help you with heavy lifting?
While in recovery is there any light duty work you could request?
Auto Insurance Information
Please list YOUR auto insurance policy information
Type of Insurance
Company Name
Address
Phone Number
Insured's Name
Policy Number
Claim Number
Insured's SS#
Insured's DOB
Insured's Employer
Agent's Name
Have you retained an attorney?
If yes, whom?
Attorney's Phone Number
Please bring the following items with you to your appointment:
• Driver's License
• Insurance Declarations Page
• Accident Report
• Health Insurance Card
• Attorney or Public Adjuster's name and phone number (if you have one)
Thank you for taking the time to fill out your paperwork online. We look forward to serving you.

OFFICE HOURS

Monday
2:45pm - 6:00pm

Tuesday
9:15am - 12:00pm
2:45pm - 6:00pm

Wednesday
2:45pm - 6:00pm

Thursday
8:30am - 12:00pm
2:45pm - 6:00pm

Friday
Closed

Saturday
8:45am - 10:00am
*BY APPOINTMENT ONLY*

Sunday
Closed

Scoles Family Chiropractic

7555 Oak Ridge Hwy
Knoxville, TN 37931

(865) 531-8025

Auto Accident History Form

After Injury

Indicate your degree of comfort while performing the following activities

Recovery

Auto Insurance Information