The incident
What happened, in your own words.
What kind of injury? Vehicle accident Slip, trip or fall Other / wellness
Where did it happen? Street, intersection or business name
Did you go to the ER or urgent care? Yes No
Briefly describe what happened (optional)
How you're feeling
This helps the doctor plan your exam.
Where does it hurt? Head Neck Upper back Lower back Left shoulder Right shoulder Arm / elbow Wrist / hand Hip Knee Ankle / foot Chest None
When did symptoms start? Right away Within 24 hours 1–3 days later More than 3 days later
Anything else? Headaches Dizziness Numbness or tingling Weakness Trouble sleeping Memory or focus problems Anxiety or flashbacks Nausea None of these
Have you missed work because of this? Yes No Not working
Health history
So the doctor can treat you safely.
Current medications Name and dose, or "none"
Allergies Medications, latex, foods, or "none"
Do you have any of these? Diabetes High blood pressure Heart disease Prior neck or back injury Arthritis Osteoporosis Blood thinners Pregnant None
Any previous accidents or injuries to the same area? Yes No
Consent and signature
Please read and tick each box. Full documents are available at the front desk.
I consent to examination and treatment by Help4Injured providers.
I acknowledge I've been offered the Notice of Privacy Practices.
I authorize Help4Injured to bill my insurer(s) directly and assign benefits for services provided.
I authorize release of my medical records to my auto insurer and, if I have one, my attorney, for this claim.
I agree to receive appointment texts. Msg & data rates may apply. Reply STOP to opt out.
Type your full name to sign
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