Personal Injury Questionaire

Name*

Phone

Address
City
State
Zip

Birth Date

Sex
S/S*
Employer's Name
Employer's Address
Yours Inc. Co.
Policy #*
Agent's Name
Name on Policy(if other than self)
Policy #*
Responsible Party's Name
Address
City
State
Zip
Policy Holder's Name
Policy #

ATTORNEY

Name

Phone

Address
City
State
Zip

Were there any witnesses?

Name(s)

NATURE OF ACCIDENT:

Date of Accident

Time of day
ampm

Were you:

Number of people in your vehicle?

Were you wearing seat belts?

What direction were you headed?

on (name of street)

What direction was other vehicle headed?

on (name of street)

Were you struck from:

Approximate speed of your car
mph

Other car
mph

Were you knocked unconscious?

If yes, for how long ?

Were police notified ?

In your own words, please describe accident

Did you have any physical complaints BEFORE THE ACCIDENT ?

If yes, please describe in detail:

Please Describe how you felt :

During the accident

IMMEDIATELY AFTER the accident

LATER THAT DAY

THE NEXT DAY

What are your PRESENT complaints and symptoms?

Do you have any congenital (from birth ) factors which relate to this problem ?

If yes , please describe

Have you ever been involved in an accident before ?

If yes , please describe , including date(s) and type(s) of accidents as well as injury(ies) received.

Where were you taken after the accident ?

Have you been treated by doctor since the accident

If yes , please list doctor's name and address

What type of treatment did you receive ?

Since this injury occurred , are your symptoms

CHECK SYMPTOMS YOU HAVE NOTICED SINCE ACCIDENT

Symptoms other than above

Have you lost time from work as a result of this accident ?

If yes, please complete this question

Last Day Worked

Type of employment

Present Salary

Are you being compensated for time lost from work

If yes, please state type of compensation you are receiving

Do you notice any activity restrictions as a result of this injury ?

If yes , please describe in detail

Other Pertinent Information

Contact us

(210) 525-9063


Moore Chiropractic
8507 McCullough Ste A-1
San Antonio, TX 78216

210-525-9063

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