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           Appointment Date:


NEW PATIENT INFORMATION

     

   


          
Where you seen in a Emergency Room?
Where X-Rays Taken? Yes     
     

      


Do you have Medical Insurance?

      
Do you have an Attorney?
     

Patient's Employer

Please describe how your accident happened?
As of today, what are your complaints & symptoms as a result of this accident?
Have you ever been treated for injuries as a result of a previous motor vehicle accident, work or slip & fall injury?
If Yes, Date      If Yes, Type of Injury
Are you PRESENTLY being treated by another Doctor or receiving physical therapy at another facility?
Were these injuries all better before this accident/injury?


Pregnant?
Cigarette Smoker?
Check Off Any of These Medical Problems You Have Had Before This Injury?




































In the past 7 years have you had any X-rays, CT Scans or MRI's?
Have the injuries from this accident caused you to change any of your activities of every day living, including social recrrreational or athletic activities?
Were you wearing a seatbelt?
Was the car moving or stopped?
Were you?
If you were hit, where?

If you were the driver did you have both hands on the steering wheel?
If you were the passengar did you brace with your hands on impact?
Did you lose consciousness?

Did you go to the hosital after the acciddent?

If Yes, When

Were you taken by ambulance?

Name of Hospital

Did you seek treatment for this accident with a Doctor after the hospital?
Have you missed any work due to this accident?
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Review of Systems
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Immunization History
Please indicate whether you had the injection or the disease
Pneumovax:

Tetanus Toxoid :

Hepatitis A & B :

Rubella:

Rubeola (measles) :

Mumps:

Chicken Pox:

Familiy History
Has any member of your family (including parents, grandparents & siblings) ever had the following






Signature and Date
The above information was supplied by me
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New Patient Information Forms