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Call for Appointment
Home
Services
Adjustment and Manipulation Therapy
Electrical Muscle Stimulation (E-stim)
Physiotherapy Services
Heat & Cold Therapy
Intersegmental Traction Therapy
Ultrasound Therapy
Orthopedic / Neurological Consults
Conditions
Auto Accident Injury
Sport Injury
Slip and Fall
Personal Injury
Wellness Center
Traumatic Rehabilitation
Pain Management
Locations
Highland Park Health Center
Huntington Park Health Center
Lynwood Health Center
Montebello Health Center
Ontario Health Services
South Central Health Center
Whittier Health Services
Blog
About Us
Intake Sample - Noriega Chiropractic Clinics, Inc.
Home
Intake Sample
Patient
Name
Date of Birth
Height
Weight
Gender
Female
Male
Age
*
Injury Information
Please Select
*
Driver
Front R.M.L. Passenger
Back R.M.L. Passenger
Pedestrian
Slip & Fall -Where (enter in comments box)
Other (enter in comments box)
Comments
Date of Accident
Time of Accident
Hours
-
12
01
02
03
04
05
06
07
08
09
10
11
Minutes
-
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Location of Accident: Traveling: N. S. E. W. on
Cross Street or Nearest Cross Street
City
Was there a police report made?
Yes
No
How did the accident occur?
When did the pain begin?
Immediately after
After after the accident
Hours after the accident
Injuries at the time of accident?
Yes
No
Seatbelt
Yes
No
Child Restraint
Yes
No
Did any part of your body strike anything?
Yes
No
If Yes, describe object and body parts.
Did you receive emergency treatment?
Yes
No
If Yes, what hospital?
How long was your stay in the hospital?
X-Rays Taken
Yes
No
If Yes, what area was x-rayed?
List treatment your received.
have you seen other doctors for this condition?
Yes
No
Name of Doctor / Clinic
X-rays taken?
Yes
No
If Yes, what part of the body?
How long did you treat?
Are you taking any medications at this time?
Yes
No
If Yes, please let the medications below.
Any complaints at this time?
Yes
No
If Yes, please explain.
Does work aggravate your complaints?
Yes
No
If yes, describe activities.
INJURY INFORMATION PAST HISTORY
Auto Accident
Treated with whom?
Areas Injured
Any residual?
Yes
No
Case
Open
Close
Work Injuries
Areas injured
Any residual?
Yes
No
Any disability
Yes
No
Case
Open
Closed
Other Injuries
Areas injured
Any residual?
Yes
No
Any disability
Yes
No
Case
Open
Closed
Fractures
Yes
No
Date
Area
Any Residuals
Yes
No
Surgeries
Yes
No
Date
Area
Surgery as a result of accident
Yes
No
Any residuals?
Yes
No
Is patient disabled?
Yes
No
From Date
To Date
Any reason for not placing patient on disability at this time?
Yes
No
If Yes, explain why.
Pregnant?
Yes
No
How many months?
L.M.P.
Last day worked?
Attorney Information
Name
Phone number
Health Insurance
Policy number
Auto Insurance
Policy number
Med Pay
Special Notes
Are you taking any medication for
Blood Pressure
Heart Disease
Birth Control
Diabetes
Other
Of Other, please explain.
History taken by:
Submit
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