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18840 SW Boones Ferry Road, Suite 110, Tualatin, OR 97062
503-941-5351
Tualatin Accident &
Injury Chiropractic
About
About The Clinic
Meet The Staff
Reviews
Blog
FAQs
Services
Auto Accident Recovery
Work Injury Recovery
Sports Injury Recovery
Chiropractic Adjustment
Regenerative Medicine
Rehabilitation / Physical Therapy
X-Rays
Massage Therapy
Cupping
Acupuncture
Symptoms
Whiplash and Ligament Injury
Neck Pain
Headaches and Migraines
Sciatica
Herniated Disc Pain
Other Conditions We Treat
New Patient Center
Your First Visit
New Patient Forms
Insurance Accepted
Frequently Asked Questions
Resources
Contact
About
About The Clinic
Meet The Staff
Reviews
Blog
FAQs
Services
Auto Accident Recovery
Work Injury Recovery
Sports Injury Recovery
Chiropractic Adjustment
Regenerative Medicine
Rehabilitation / Physical Therapy
X-Rays
Massage Therapy
Cupping
Acupuncture
Symptoms
Whiplash and Ligament Injury
Neck Pain
Headaches and Migraines
Sciatica
Herniated Disc Pain
Other Conditions We Treat
New Patient Center
Your First Visit
New Patient Forms
Insurance Accepted
Frequently Asked Questions
Resources
Contact
Tualatin Accident and Injury Chiropractic
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Bars
Vehicle Accident Form
"
*
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Welcome to Tualatin Accident and Injury Chiropractic. The following forms will provide us with the necessary information to treat you.
Let's start with the general information about you and your medical history.
First Name:
*
Last Name:
*
Email Address:
*
Phone Number:
*
Address
*
Street Address:
Address Line 2:
City:
State:
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip:
Date of Birth:
*
MM slash DD slash YYYY
Occupation:
*
Employer:
Are you a public servant?
Yes
No
Insurance Company Name:
Policy Number:
Member OR Claim Number:
Primary Doctor:
Preferred Hospital:
Date of Last Exam:
MM slash DD slash YYYY
Any new course of treatment?
Yes
No
Have you ever been treated by a chiropractor before?
Yes
No
When were you last treated?
MM slash DD slash YYYY
Did you get X-Rays?
Yes
No
Date of last X-Rays??
MM slash DD slash YYYY
What physical injuries or pain have you sought physical therapy or chiropractic for? (check all that apply)
Head
Neck
Back
Shoulder
Knee
Other (explain below)
Please explain the "other" physical injuries or pain have you sought physical therapy or chiropractic for:
Did treatment help?
Yes
No
Is there lingering pain?
Yes
No
Do we have your permission to communicate with your prior health care providers if necessary to improve your treatment outcome?
Yes
No
How did you hear about us?
*
Google
Facebook (Meta)
Instagram
Walk-In
Referral
Who referred you?
Nice work and thank you for providing that information. Next, let's learn a little more about your motor vehicle accident.
When did the accident happen?
MM slash DD slash YYYY
What seated position were you inside the vehicle?
Driver
Front Passenger
Middle Passenger
Left Rear Passenger
Middle Rear Passenger
Right Rear Passenger
What was the damage to the vehicle?
Mild
Moderate
Extensive
Totaled
How was the visibility of the road?
Poor
Fair
Good
How were the weather conditions?
Clear
Raining
Windy
Foggy
Snowing
Please explain how the accident happen:
What was the point of impact on your vehicle?
Left
Front End
Rear End
Right
Left Front
Left Rear
Right Front
Right Rear
Did you see the accident coming?
Yes
No
Were you wearing a seatbelt?
Yes
No
Did your air bags deploy?
Yes
No
What was the position of your vehicle's headrest?
Even with top of the head
Even with bottom of the head
Middle of neck
Did you strike with anything inside the vehicle?
Yes
No
Where specifically did you strike? (check all that apply)
Steering Wheel
Windshield
Arm Rest
Dashboard
Side Door
Side Window
Airbag
Other (explain below)
Please explain the "other" areas where you struck inside the vehicle:
Immediately after the accident did you feel dazed?
Yes
No
Did you lose consciousness?
Yes
No
Which way was your head turned during the accident?
Facing Straight
Turned To The Right
Turned To The Left
Was your head injured?
Yes
No
Immediately after the accident did you experience: (check all that apply)
Headache
Neck Pain
Lower Back Pain
Did you see another doctor before coming here?
Yes
No
Did you go to the hospital?
Yes
No
How did you get to the hospital?
Ground Ambulance
Air Ambulance
Drove Yourself
Someone Drove You
Police
Which of the following test were preformed at the hospital? (check all that apply)
X-Rays
MRI
CT Scan
Lab Work
Do you feel that your condition is improving?
Yes
No
Remains The Same
Have you lost time from work?
Yes
No
Are you sleeping well?
Yes
No
Does the pain wake you up?
Yes
No
Did you have this issue before?
Yes
No
Insurance Name:
Member ID/Claim Number:
DOI:
Adjuster Name:
Adjuster Phone Number:
Adjuster Email:
Attorney Firm:
Attorney Name:
Attorney Phone:
Anything else we should know prior to your first visit?
18840 SW Boones Ferry Road, Suite 110
Tualatin, OR 97062
503-941-5351
About
About The Clinic
Meet The Staff
Reviews
Blog
FAQs
Services
Auto Accident Recovery
Work Injury Recovery
Sports Injury Recovery
Chiropractic Adjustment
Regenerative Medicine
Rehabilitation / Physical Therapy
X-Rays
Massage Therapy
Cupping
Acupuncture
Symptoms
Whiplash and Ligament Injury
Neck Pain
Headaches and Migraines
Sciatica
Herniated Disc Pain
Other Conditions We Treat
New Patient Center
Your First Visit
New Patient Forms
Insurance Accepted
Frequently Asked Questions
Resources
Contact
About
About The Clinic
Meet The Staff
Reviews
Blog
FAQs
Services
Auto Accident Recovery
Work Injury Recovery
Sports Injury Recovery
Chiropractic Adjustment
Regenerative Medicine
Rehabilitation / Physical Therapy
X-Rays
Massage Therapy
Cupping
Acupuncture
Symptoms
Whiplash and Ligament Injury
Neck Pain
Headaches and Migraines
Sciatica
Herniated Disc Pain
Other Conditions We Treat
New Patient Center
Your First Visit
New Patient Forms
Insurance Accepted
Frequently Asked Questions
Resources
Contact
Book Appointment
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