Get Personal Injury Questionnaire - Schofield Chiropractic Training

This guide provides clear instructions on completing the Personal Injury Questionnaire tailored for users seeking care following an injury. By carefully filling out this form online, you can ensure that all necessary information is accurately conveyed to facilitate your treatment.

Follow the steps to complete your form online effectively.

1. Press the ‘Get Form’ button to obtain the questionnaire and open it in your preferred digital editor.
2. Begin by entering your personal information. Fill in your name, phone number, address, age, birthdate, sex, social security number, insurance company, and policy details as requested.
3. In the attorney section, indicate whether you have appointed an attorney by checking the appropriate box. If yes, provide the attorney's name, phone number, and address.
4. For the nature of the accident section, enter the date of the accident. Specify if you were the driver or passenger, and provide details about your vehicle and any other vehicles involved.
5. Indicate the conditions of the pavement during the accident and whether you were wearing a seatbelt. Answer questions regarding the police notification, whether the vehicle was totaled, and if there were any witnesses.
6. Continue with questions asking about your head position during the accident, if you were knocked unconscious, directions of travel, and describe the accident in your own words.
7. Document any physical complaints you had prior to the accident and describe how you felt immediately after and the following day.
8. Answer questions regarding current complaints, any congenital factors, previous illnesses, and if you had been involved in prior accidents.
9. Input information about post-accident treatment, including medications and their effects on your symptoms.
10. Assess your symptoms since the accident, specify if you lost time from work, and describe any activity restrictions you've noticed.
11. Reflect on how the injury has impacted your overall enjoyment of life, and provide any other relevant information you believe is important for review.
12. Lastly, sign and date the questionnaire at the bottom of the form to certify the information provided is accurate.

Complete your Personal Injury Questionnaire online to ensure a thorough evaluation of your care.