Advanced Health & Physical Therapy Solutions

Step 1 of 7Personal Information

Personal Information

First Name*

Last Name*

Date of Birth*

Email Address*

Phone (Primary)*

Home Address

City

State

ZIP

Accident Details

Tell us what happened — these details are important for both your treatment plan and any insurance claim.

Date of Accident*

Approximate Time

Accident Location

Your role in the vehicle*

DriverFront passengerRear passengerPedestrianCyclist

Were you at fault?

NoYesPartiallyNot yet determined

Were you wearing a seatbelt?

YesNoN/A

Police report filed?

YesNoNot sure

Police report number (if known)

Were you transported by ambulance?

YesNo

Did you visit the ER or urgent care? Where, and when?

In your own words, describe what happened.

Vehicle Information

Year

Make

Model

Vehicle damage

NoneMinorModerateSevereTotal loss

Did airbags deploy?

YesNoN/A (no airbags)

Insurance & Legal

We bill auto-insurance medical-payments coverage when available — please bring or send any documentation you have.

Your auto insurance carrier

Policy number

Claim number (if assigned)

Adjuster name

Adjuster phone

Do you have med-pay coverage?

YesNoNot sure

Other party's auto insurance (if known)

Do you have an attorney for this case?

YesNoConsidering it

Attorney name & firm

Attorney phone

Your Injuries

Areas of pain or injury (check all)

HeadNeckShoulderUpper backMid backLower backHipKneeAnkle / FootArmWrist / HandChestOther

Current pain level (0 = none, 10 = worst)

012345678910

No painWorst

When did your symptoms first appear?

Immediately after the accidentWithin hoursNext dayA few days later

Did you lose consciousness?

NoBrieflyMore than a few seconds

Describe your current symptoms

Treatment received so far

Relevant Medical History

Current medications & supplements

Known allergies

Any prior injuries to the same areas?

Are you pregnant or nursing?

NoPregnantNursing

Consent & Authorization

I authorize Advanced Health & Physical Therapy Solutions to perform chiropractic examination and treatment as needed. I understand chiropractic treatment carries risk and I have had the opportunity to ask questions. I authorize release of medical information necessary to process auto-insurance and any related legal claims. I am financially responsible for charges not covered by insurance.

I have read and agree to the terms above.*I authorize this practice to share my records with my attorney listed above (if any).

Patient Signature*

Typing your name acts as your electronic signature (ESIGN Act).

Date*