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About Us
- Meet the Doctor
- Testimonials
Injury Treatment
Pain Treatment
- Chiropractic Services
- Chronic Pain & Injuries
Patient Center
Contact

(503) 585-2585 Appoinment

Phone
(503) 585-2585

Address
1765 State St a,
Salem, OR 97301

Phone
(503) 585-2585

(503) 585-2585 Appoinment

About Us
- Meet the Doctor
- Testimonials
Injury Treatment
Pain Treatment
- Chiropractic Services
- Chronic Pain & Injuries
Patient Center
Contact

Home

Patient Registration Form (Auto and Personal Injury)

Patient Registration Form (Auto and Personal Injury)

Date

Name*

Middle Initial

Last Name*

Phone *

Address

Cell#

City

State

Zip Code

Work#

SSN#

DL#

Date of Birth

Age

Gender

Male Female

Employer

Occupation

Address

Phone#

Emergency Contact

Phone#

Private Physician

Phone#

Where you referred to the office by any healthcare provider?

Yes No

INSURANCE INFORMATION / METHOD OF PAYMENT

Auto Insurance Slip and Fall Personal Injury General Health Insurance

Insurance Company

Phone#

Claims AJD.

Phone#

Ext

Policy #

Claim #

Are you the policyholder?

Yes No

PLEASE INDICATE REGION(S) OF COMPLAINT

Headache Neck Pain Upper / Mid Back Lower Back Shoulder / Elbow / Wrist / Hand / Fingler Hip / Thigh / Knee / Ankle / Foot Rib / Abdomen / Chest Other

If other

When did your symptoms first appear?

Was there a specific injury?

Yes No

If yes, explain

is this condition getting progressively worse?

Yes No Unknown

Overall, rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)

Is or constant or does it come and go?

How often do you have this pain?

Does it interfere with your

Work Sleep Daily Routine Recreation

Activities that are painful to perform

Sitting Standing Walking Bending Lying

Check symptoms apparent since the accident:

Dizziness Memory Loss Headache Blurred Vision Buzzing in Ears Ringing in Ears Chest Pain Irritability Fatigue Tesnsion Neck Pain Stiff Neck Jaw Problems Arms / Shoulder Pain Numb Hands / Fingers Difficulty Sleeping Shortness of Breath Upset Stomach Nausea Mid Back Pain Lower Back Pain Back Stiffness Leg Pain Numb Feet / Toes

PLEASE INDICATE REGION(S) OF COMPLAINT

Date of Injury

Time of Injury

Location of Accident

Auto vs Auto Auto vs Truck Motorcycle Auto vs Bus Auto vs Pedestrian Slip and Fall Other

if Other

Briefly describe accident

Driver Passender Front seat Back seat

Seatbelt Shoulder Harness

Body Parts Struck?

Yes No

If yes, Please list

Emergency Treatment

Yes No

If yes, where

Were X-Rays Taken?

Yes No

Where?

Custom Loss of consciousness?

Yes No

Work Related? If Yes, Any Loss Work?

Yes No

MEDICAL HISTORY

Date of last physical exam

Prior Imaging ( X-Rays, MRI, CT Scan ETC.)

Yes No

Date

Previous Chiropractic Treatment

Yes No

Where

Arthritic Condition

Yes No

Cancer

Yes No

Diabetes

Yes No

Heart Problems

Yes No

High Blood Pressure

Yes No

Vascular Condition

Yes No

Lung Problems

Yes No

Unusual Childhod Deseases

Yes No

Currently Pregnant

Yes No

Due Date

Recreational Drugs

Yes No

Tobacco Use

Yes No

How Much?

Alcohol Use

Yes No

How Much?

Allergies

Yes No

Birth Control Medication

Yes No

Exercise

Moderate Daily Heavy

Medications / Allergies / Injuries

List Medications

Allergic to Medication

Allergies

Surgeries / Hospitalizations / Injuries

Prior Auto Accidents or Work Injuries

AUTHORIZATION TO RELEASE MEDICAL INFORMATION / FINANCIAL AGREEMENT

I UNDERSTAND AND AGREE THAT REGARDLESS OF INSURANCE COVERAGE, I AM LIABLE FOR ANY CHARGES INCURRED AS A RESULT OF SERVICES RENDERED TO ME AT DC CHIROPRACTIC CENTER. IF THIS ACCOUNT IS ASSIGNED TO AN ATTORNEY FOR COLLECTION AND/OR SUIT, THE PREVAILING PARTY SHALL BE ENTITLED TO REASONABLE ATTORNEY’S FEES AND COST OF COLLECTIONS.

I AUTHORIZE RELEASE OF PATIENT MEDICAL RECORDS TO THIRD PARTIES REQUIRING THESE RECORDS FOR DETERMINATION OF FINANCIAL LIABILITY.

Signature

Date

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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DC Chiropractic Center

Address

1765 State St a,
Salem, OR 97301

Phone

(503) 585-2585

View Directions

Monday

9:00 am - 6:00 pm

Tuesday

9:00 am - 4:00 pm

Wednesday

9:00 am - 6:00 pm

Thursday

9:00 am - 4:00 pm

Friday

9:00 am - 6:00 pm

Saturday

Closed

Sunday

Closed

We look forward to hearing from you

Name*

Email *

Phone *

Comments

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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