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Home
About
Our-services
Forms
- Intake
- Accident detail
Blog
Products
Contact

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Accident detail form

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Accident detail form

Welcome to HealthCare Management Group INC.! In order to serve you better, please take a moment to complete this form. If you require assistance, please call or email the office.

Accident/Injury Details (MVA, Slip-fall, WSIB)

Please describe the accident/Injury in your own words:

Please describe the accident/Injury in your own words:

Accident Location:

Were you a

Driver Front Passenger Rear Passenger?

Were you at fault

Yes No

Did airbags deploy?

Yes No

Did airbag hit you?

Did you go to hospital after Accident?

Yes No

If Yes

Injury

1. Did you hit your face or head during the impact?

Yes No

If Yes, explain

2. Was there a period of Loss of consciousness or Blackout?

Yes No

If Yes, for how long?.

4. Name/indicate the area of complaint

Headache Neck Upper Back R/L Shoulder R/L Arm R/L Wrist Low Back R/L Hip R/L Knee R/L Ankle R/L Foot Ribs Shooting/Referral pain Weakness Fatigue Sleep Difficulty Anxiety Phobia Irritability/Anger Low mood Nausea Memory Lapses Any cuts or bruises: Areas?. ______________ Tingling/Numbness Areas?. ______________

Any diagnostics (Xray, Ultrasound, MRI, etc) of the pain area

Yes No

If Yes, Specify

Treatment to date, Medications, etc

Yes No

If Yes, Specify

Pre-Existing

• Any Previous Accident/injury/pain?

Yes No

If Yes, Indicate

• Any treatment or surgery or medication before the accident?

Yes No

If Yes, Indicate

• Any Xray, ultrasound, MRI/CT scan before accident?

Yes No

If Yes, Indicate

• Area performed and findings?

Social and Occupational History

Were you working at the time of the accident?

Yes (F/T, P/T) No

If Yes, Job Description

Did you stop working due to accident?

Yes No

If Yes, when did you stop work?.

Partially returned

Modified hrs Modified tasks

Is the pain affecting your daily activities, social, etc.? Specify

Recreational activities/sports/Lifestyle prior to accident that are unable to do after injury? Specify

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About
Our Services
Resources
Physiotherapy
Acupuncture
Orthopedic Products
Massage Therapy
Laser Therapy
Compression Socks & Stockings
Electrical Muscle Stimulation
Ultrasound (Therapy)
Privacy
Site Map
Contact

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