Discover Chiropractic
151 North Sunrise Avenue
Roseville, CA 95661-4516
ph: 916.772.7722

Office Hours:
Mon & Wed: 8am – noon & 3pm – 6pm
Tues: 3pm – 6:30pm
Thurs: 8am – noon & 3pm – 6:30pm
Saturday: Once Per Month By Appt Only

Personal Injury Questionnaire

PERSONAL INJURY QUESTIONNAIRE
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  18. Have you reported the accident to your insurance company?
ABOUT YOUR ATTORNEY
  11. Were you...
  16. Were you wearing your seatbelt?
  18. What direction were you headed?
  20. What direction was the other vehicle headed?
  23. You were struck from:
  27. Were you ever unconscious?
  30. Were the Police called?
  35. Have you been treated by another doctor since the accident?
  38. Did you have any physical complaints BEFORE THE ACCIDENT?
  41. Please describe how you felt:
  47. Do you have any previous illnesses that relate to this case?
  51. Have you ever been involved in an accident before?
  54. Since the injury occured, my symptoms are...
  56. Select the symptoms you have noticed since the accident
  59. Have you lost time from work as a result of the accident?
  64. Are you being compensated for lost time from work?
  67. Do you notice any activity restrictions as a result of this injury?
 

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