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2525 W Main St, Norristown, PA 19403
610-630-9800
Lifelinechiropractic@gmail.com
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About Us
Meet The Doctor
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New Patients
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Atlas Orthogonal / The Upper Cervical Care Difference
spine, back, sciatica, and extremity pain corrections
decompression therapy
Laser Therapy
Massage Therapy
Upper Cervical Video
Functional Corrective Nutrition
Conditions
Migraine Headaches
Vertigo/Menieres/Trigeminal Neuralgia
Neck Pain
Low Back Pain
Concussion
Anxiety
Arm/Shoulder Pain
Blogs
Whiplash, Neck Injury, and Meniere’s Disease
Struggling with Vertigo and Dizziness in the Philadelphia Area?
Contact Us
Home
About Us
About Us
Meet The Doctor
New Patient
New Patients
Services
Atlas Orthogonal / The Upper Cervical Care Difference
spine, back, sciatica, and extremity pain corrections
decompression therapy
Laser Therapy
Massage Therapy
Upper Cervical Video
Functional Corrective Nutrition
Conditions
Migraine Headaches
Vertigo/Menieres/Trigeminal Neuralgia
Neck Pain
Low Back Pain
Concussion
Anxiety
Arm/Shoulder Pain
Blogs
Whiplash, Neck Injury, and Meniere’s Disease
Struggling with Vertigo and Dizziness in the Philadelphia Area?
Contact Us
APPOINTMENT REQUEST
Home
About Us
About Us
Meet The Doctor
New Patient
New Patients
Services
Atlas Orthogonal / The Upper Cervical Care Difference
spine, back, sciatica, and extremity pain corrections
decompression therapy
Laser Therapy
Massage Therapy
Upper Cervical Video
Functional Corrective Nutrition
Conditions
Migraine Headaches
Vertigo/Menieres/Trigeminal Neuralgia
Neck Pain
Low Back Pain
Concussion
Anxiety
Arm/Shoulder Pain
Blogs
Whiplash, Neck Injury, and Meniere’s Disease
Struggling with Vertigo and Dizziness in the Philadelphia Area?
Contact Us
2525 W Main St, Norristown, PA 19403
610-630-9800
support@demolink.com
1
about you
2
auto related accident
3
work related 2b
4
After Injury
5
Recovery
6
Today,s Date
MM slash DD slash YYYY
File #
Name
Email
Date & Time of Accident
a.m
p.m
Were you the
Driver
Front Passenger
Rear Passenger
If a traffic violation was issued, to whom was it issued?
Number of people in accident vehicle?
Did the police come to the accident site?
Yes
No
was a police report filed?
Yes
No
Were there any witnesses?
Yes
No
Were you wearing your seat belt?
Yes
No
Was this vehicle equipped with airbags?
Yes
No
If yes, did it / they inflate?
Yes
No
In relation to the base of your skull, where was the headrest?
Above
Below
At base of skull
What did your vehicle impact?
Another vehicle
Other
If other, explain
Did any part of your body strike anything in the vehicle?
Yes
No
If yes, please describe
Make & model of the vehicle you were occupying?
Name of the location/street on which you were traveling?
In which direction were you headed?
N
S
E
W
What was the approx. speed of your vehicle?
Did the impact to your vehicle come from the
Front
Rear
Right Side
Left Side
Other
During impact, were you facing
Right
Left
Forward
Were you
Aware or
Surprised by the impact?
If accident vehicle made impact with another vehicle
Make and model of that other vehicle?
Direction other vehicle was headed?
N
S
E
W
Speed of the other vehicle?
In your words, please describe the accident
Date & Time of Accident
a.m
p.m
Was your accident directly related to your work?
Yes
No
Briefly describe the events that occurred just before and during your accident
Give the address where accident occurred (if other than employer,s address)
Was anyone else present during your accident?
Yes
No
Did you report your accident to your employer?
Yes
No
What recommendations did your employer make just after your accident?
Has this type of accident happened to you before?
Yes
No
To the best of your knowledge, has this accident occurred in your workplace before?
Yes
No
In general
Is your job physically stressful?
Yes
No
Is your job mentally stressful?
Yes
No
Is your workplace noisy?
Yes
No
Have you changed jobs in the last year?
Yes
No
Did accident render you unconscious?
Yes
No
If yes, for how long?
Please describe how you felt immediately after the accident
Have you gone to a Hospital or seen any other Doctor?
Yes
No
When did you go?
Just after accident
The next day
2 days plus
How did you get there?
Ambulance or
Private transporation
Was he/she a
D.C
M.D
D.O
D.D.S
Describe any treatment you received
Were X-rays taken?
Yes
No
Was medication prescribed?
Yes
No
Have you been able to work since this injury?
Yes
No
Are your work activities restricted as a result of this injury?
Yes
No
Indicate the symptoms that are a result of this accident
Dizziness
Difficulty sleeping
Jaw problems
Nausea
Memory loss
Irritability
Arms/Shoulder pain
Back pain
Headache(s)
Fatigue
Numb Hands/Fingers
Lower back pain
Blurred vision
Tension
Chest pain
Back stiffness
Buzzing in ear
Neck pain
Shortness of breath
Leg pain
Ears ringing
Neck stiff
Stomach upset
Numb Feet/Toes
Other
Is your condition getting worse?
Yes
No
Constant
Comes & goes
Indicate your degree of comfort while performing the following activites
Lying on back
Lying on side
Lying on stomach
Sitting
Standing
Stretching
Lovemaking
Walking
Running
Sports
Working
Lifting
Bending
Kneeling
Pulling
Reaching
Have you retained an attorney
Yes
No
If yes, whom
His/Her Phone #
To evaluate the effect that continuing work will have on your recovery please complete the following
How many hours are in your normal work day?
Please indicate your daily job duties and any activites which you are occasionally asked to perform
Standing
Driving
Operating equipment
Sitting
Twisting
Work with arms above head
Walking
Crawling
Typing
Lifting
Bending
Stooping
Other
What position can you work in with minimum physical effort and for how long
N/A
Prior to the injury were you capable of working on an equal basis with other your age?
Yes
No
N/A
Do you work with other who can help you with any heavy lifting?
Yes
No
N/A
While in recovery , is there any light duty work you could request?
Yes
No
N/A
Type of Insurance
Co. Name
Address
Phone #
Insured's Name
Policy #
Claim #
Insured's SS #
D.O.B
MM slash DD slash YYYY
Insured's Employer
Agent's Name
If any of your medical or account information has changed please inform our front desk personnel. Please remembetr you are ultimately responsible for your account.
Signature
OFFICE USE ONLY OFFICE USE ONLY
Date
MM slash DD slash YYYY
OFFICE USE ONLY OFFICE USE ONLY
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