Motor Vehicle Intake

Motor Vehicle Accident Intake

Visibility at Time of Accident*
Please select at least one option
Road Conditions at Time of Accident*
Please select at least one option
Were you Wearing a Seatbelt*
Please select at least one option
Did You Brace for Impact?*
Please select at least one option
Were the Brakes On?*
Please select at least one option
Did the Airbag Deploy?*
Please select at least one option
Did Your Head Hit the Headrest?*
Please select at least one option
Loss of Consciousness*
Please select at least one option
Did You Go to the Hospital?*
Please select at least one option
How Did You Get There?
Was Any Imaging Done? (Xray, CAT, MRI)
Have You Missed Work/School?
Were You Prescribed and/or Are Anything for Pain?
Have You Ever Experienced Similar Symptoms to What You are Experiencing Now?
Have You Seen Other Doctors For This Injury?*
Please select at least one option

CHIEF COMPLAINT #1

PROVOKING (What Aggravates Your Injury)*
Please select at least one option
PALLIATIVE (What Makes It Feel Better)*
Please select at least one option
QUALITY (Describe the Pain)*
Please select at least one option
Any Sensations RADIATING Into the Following?
Describe the Radiating
PATTERN (Time of Day Most Aggravated)*
Please select at least one option

CHIEF COMPLAINT #2

PROVOKING (What Aggravates Your Injury)*
Please select at least one option
PALLIATIVE (What Makes It Feel Better)*
Please select at least one option
Any Sensations RADIATING Into the Following?
QUALITY (Describe the Pain)*
Please select at least one option
Describe the Radiating
PATTERN (Time of Day Most Aggravated)*
Please select at least one option

PLEASE MARK WHERE YOUR PAIN IS LOCATED. USE THE FOLLOWING KEY:


B= Burning S= Stabbing A= Aching N= Numbness P= Pins and Needles O= Other

Thank you for taking the time to fill out this form.

Office Hours

Monday

10:00 am - 7:00 pm

Tuesday

10:00 am - 7:00 pm

Wednesday

10:00 am - 7:00 pm

Thursday

10:00 am - 7:00 pm

Friday

10:00 am - 7:00 pm

Saturday

10:00 am - 5:00 pm

Sunday

10:00 am - 5:00 pm

Monday
10:00 am - 7:00 pm
Tuesday
10:00 am - 7:00 pm
Wednesday
10:00 am - 7:00 pm
Thursday
10:00 am - 7:00 pm
Friday
10:00 am - 7:00 pm
Saturday
10:00 am - 5:00 pm
Sunday
10:00 am - 5:00 pm

Location

--mi

Holistic Health Clinic

Address

4670 SW Washington Ave
Beaverton, OR 97005

Contact Information (503) 646-8575

(503) 526-0783

New Patient Inquiry