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Accident Injury Form

Accident / Injury

Welcome to the healthcare management goup inc.! In order to serve ypu better, please take a moment to complete this form, if you require assistance, please call or email the office.

Accident / Injury form

Patients Information ( please complete all of the fields below )

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

Please describe the accident /injury in your own words

Accident location

Were you a

Driver
Front Passenger
Rear Passenger

Layout

Were you at fault?

Yes
No

Did the airbags deploy?

Yes
No

Layout

If yes, where

Any bruises or cuts?

Layout (copy)

Did the police come to the scene?

Yes
No

Did you go to hospital after accident?

Yes
No

Injury

Layout

Did you hit your head during the impact?

Yes
No

Specify

Layout

Area of body impact and to what structure?

Any bruises or cuts?

Was there a period of loss of consciousness of black out?

Yes
No

Layout

Any cut or bruises?

Yes
No

Area

Name / Indicae the area of complaint

Neck
Low back
Upper back
Shoulder
Arm
Wrist
knee
Ankle
Feet

Layout

Headache area

Weakness Area

Tingling / Numbness area

Shooting / Refferal pain area

Fatigue
Sleep Difficulty
Anxiety
Phobia
Irritability / Anger
Low Mood
Nausea or Vomiting

other

Layout

Any diagnostics ( X-ray, ultrasound, MRI, etc ) of the pain area

Yes
No

treatment to date, medications

Yes
No

Pre Existing

Any previous accident / injury / pain?

Yes
No

Any treatment or surgery or medication before the accident?

Yes
No

Field #53 (copy)

Any X-ray, ultrasound, MRI / CT scan?

Yes
No

Area performed any findings?

Social & occupational history

Field #53 (copy) (copy)

Were you working at the time of the accident?

Yes
No

If yes, job description

Field #53 (copy)

Did you stop working due to accident?

Yes
No

Partially returned

Yes
No

Layout (copy)

Is the pain affecting your daily activities, social etc?

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

HCMG

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Telephone: 905-882-1006 | 905-882-1007
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Accident Injury Form

Accident / Injury

Welcome to the healthcare management goup inc.! In order to serve ypu better, please take a moment to complete this form, if you require assistance, please call or email the office.

Accident / Injury form

Patients Information ( please complete all of the fields below )

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

Injury

Pre Existing

Social & occupational history

HCMG

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