Please Circle ALL Areas of Complaint

1433 Bridge Street

New Cumberland, PA 17070

Ph: 717-774-5376

Fax: 717-770-2059

Motor Vehicle Accident Intake Form

Please circle ALL areas of complaint:

FRONT BACK RIGHT LEFT

Your Health History:

What is your: Height: ____ft____inWeight: ______lbs

Any previous injuries or trauma (car accidents, sports injuries, etc) YES NO If yes, please explain: ______

______

Have you ever had any of these symptoms prior to your injury? YES NO

If yes, please describe: ______

______

Any illnesses past or current you have had? (please circle)

Cancer Eyes, Ears, Nose or Throat Reproductive Stroke Allergies: ______

Diabetes High Blood Pressure Skin Heart ______

Respiratory Lymphatic/Circulation Breast Lymes Disease ______

Intestinal Mental or Emotional Neurological Infections ______

Please list ALL Surgeries you have had (*Including any Cosmetic Procedures) Give Year/ Type of Surgery:

______

______

Please list ALL medications, vitamins or supplements that you are presently taking: ______

______

______

______

Female Patients: ***Incase X-rays or other tests are needed***

Are you or any POSSIBILITY that you are currently pregnant? YES NO

Start date of last menstrual period? ______

Are you taking or using any birth control devices? YES NO If yes, what? ______

FAMILY HEALTH HISTORY:

Any immediate family members (Parents or Children) have had or have any of the following? (circle please)

Cancer Eyes, Ears, Nose or Throat Reproductive Stroke Intestinal

Diabetes High Blood Pressure Skin Heart Mental or Emotional

Respiratory Lymphatic/Circulation Breast Lyme’s Disease Neurological

Please list specifics: ______

______

Social & Occupational History:

Highest Level of Education:High SchoolSome CollegeCollege Grad/TradePost Graduate

Job Title: ______Company: ______

Currently live with: SELF SPOUSE PARENTS GRANDPARENTS OTHER: ______

Recreational activities/hobbies that you participate in: ______

Do you play any sports or go to the gym? YES NO How Often: ______

Have you used any Tobacco products? YES, CURRENTLY NO, BUT PREVIOUS NEVER

Type: ______# of packs/cans/pouches per day ______Years Used: ______

Have you used any illegal drugs now or in the past? YES NO Type: ______How Long:____years

If yes, are you still using the drug(s)? YES NO

Do you currently consume alcohol? YES NO How much? ______How often? ______

I have read the above information and certify it to be true and correct to the best of my knowledge. I understand that it is my responsibility to update my medical history or changes in my medical health status to the provider immediately.