Motor Vehicle Collision Intake Form

Please complete all sections as thoroughly as possible. Each symptom or complaint must be entered on its own symptom line below. Thorough documentation helps Dr. Bussard provide the best care and supports your personal injury case.

Important: Please complete ALL sections of this form before your first appointment. Each symptom you are experiencing since the accident should be entered separately in the symptom sections below. If you have questions, call us at (253) 854-7700.

Patient Information

Patient Name *

Date *

Address *

City *

State *

Zip Code *

Home Phone

Work Phone

Cell Phone *

Email Address *

Date of Birth *

Sex

Male Female

Marital Status

Married Single Divorced Widowed

Occupation

Employer

Have you ever received Chiropractic Care?

Yes No

If yes, when?

Name of most recent Chiropractor

1. Previous Treatments & Date of Loss

Previous interventions, treatments, medications, surgery, or care you've sought for your complaint(s):

Date of Accident *

Were you the Driver or Passenger? *

Driver Passenger Pedestrian

How many people were in your vehicle? *

1 (just me) 2 3 4 5+

Were any other occupants injured?

Yes No Unknown

2. Since the Motor Vehicle Collision, have you experienced any of the following?

A. Loss of Range of Motion:

Yes No

If yes, what body parts?

B. Visual Disturbance:

Yes No

Blurring (L/R) — % of time: Floaters (L/R) — % of time: Vision Loss (L/R) — % of time: Hypersensitivity (L/R) — % of time:

C. Dizziness:

Yes No

% of time:

D. Anxiety:

Yes No

% of time:

E. Depression:

Yes No

% of time:

F. Difficulty Sleeping:

Yes No

3. Past Health History

A. Please indicate if you have a history of any of the following:

Anticoagulant use Heart problems / high blood pressure / chest pain Bleeding problems Lung problems / shortness of breath Cancer Diabetes Psychiatric disorders Bipolar disorder Major depression Schizophrenia Stroke / TIA's None of the above

Other:

B. Previous Injury or Trauma:

Have you ever broken any bones? If yes, which?

C. Allergies:

D. Medications (list all current medications and reason for taking):

E. Surgeries (list date and type):

F. Females — Pregnancies and outcomes:

4. Family Health History

Do you have a family history of? (Check all that apply):

Cancer Strokes / TIA's Headaches Cardiac disease Neurological diseases Adopted / Unknown Cardiac disease below age 40 Psychiatric disease Diabetes None of the above

Other:

Cause of parents or siblings death / Age at death:

5. Social and Occupational History

Job Description:

Work Schedule:

Recreational Activities:

Lifestyle (hobbies, exercise, alcohol, tobacco, drug use, diet):

6. Review of Systems

Pulmonary (lung-related):

Asthma / difficulty breathing COPD Emphysema None of the above

Other:

Cardiovascular (heart-related):

Heart surgeries Congestive heart failure Murmurs / valvular disease Heart attacks / MIs Heart disease / problems Hypertension Pacemaker Angina / chest pain Irregular heartbeat None of the above

Other:

Neurological (nerve-related):

Visual changes / loss of vision One-sided weakness of face or body History of seizures One-sided decreased feeling in face or body Headaches Memory loss Tremors Vertigo Loss of sense of smell Strokes / TIAs None of the above

Other:

Endocrine (glandular/hormonal):

Thyroid disease Hormone replacement therapy Injectable steroid replacements Diabetes None of the above

Other:

Renal (kidney-related):

Renal calculi / stones Hematuria (blood in urine) Incontinence Bladder infections Difficulty urinating Kidney disease Dialysis None of the above

Other:

Gastroenterological (stomach-related):

Nausea Difficulty swallowing Ulcerative disease Frequent abdominal pain Hiatal hernia Constipation Pancreatic disease Irritable bowel / colitis Hepatitis / liver disease Bloody or black tarry stools Vomiting blood Bowel incontinence Gastroesophageal reflux / heartburn None of the above

Other:

Hematological (blood-related):

Anemia Regular anti-inflammatory use (Motrin/Ibuprofen/Naproxen/Aleve) HIV positive Abnormal bleeding / bruising Sickle-cell anemia Enlarged lymph nodes Hemophilia Hypercoagulation / deep venous thrombosis / blood clots Anticoagulant therapy Regular aspirin use None of the above

Other:

Dermatological (skin-related):

Significant burns Significant rashes Skin grafts Psoriatic disorders None of the above

Other:

Musculoskeletal (bone/muscle-related):

Rheumatoid arthritis Gout Osteoarthritis Broken bones Spinal fracture Spinal surgery Joint surgery Arthritis (unknown type) Scoliosis Metal implants None of the above

Other:

Psychological:

Psychiatric diagnosis Depression Suicidal ideations Bipolar disorder Homicidal ideations Schizophrenia Psychiatric hospitalizations None of the above

Other:

New Patient History — Symptom Sections

Important Instructions: Please complete a separate symptom section for EACH symptom or complaint you are experiencing since the accident. Start at the top of your body and work your way down (example: Headache, Neck Pain, Shoulder Pain, Back Pain, etc.). Every symptom needs its own section — do not combine multiple symptoms into one section.

Symptom 1

Enter ONE symptom or complaint per section. Start at the top of your body and work down.

Symptom / Complaint: *

Pain scale (1-10):

1 2 3 4 5 6 7 8 9 10

% of waking time:

5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

When did this symptom begin?

Was this a result of the motor vehicle collision?

Yes No

Did you have this symptom BEFORE the motor vehicle collision?

Yes No

If yes, what was the intensity (1-10) and frequency before the accident?

What makes this symptom WORSE? (check all that apply):

Bending neck forward Bending neck backward Tilting head left Tilting head right Turning head left Turning head right Bending forward at waist Bending backward at waist Tilting left at waist Tilting right at waist Twisting left at waist Twisting right at waist Sitting Standing Getting up from sitting Lifting Any movement Driving Walking Running Nothing

Other (describe):

What makes this symptom BETTER? (check all that apply):

Rest Ice Heat Stretching Exercise Massage Pain medication Muscle relaxers Nothing

Other (describe):

Quality of symptom (check all that apply):

Sharp Dull Achy Burning Throbbing Piercing Stabbing Deep Nagging Shooting Stinging

Other (describe):

Does this symptom radiate to another part of your body?

Yes No

If yes, where does it radiate?

Is the symptom worse at certain times of day?

Morning Afternoon Evening Night Unaffected by time of day

Symptom 2

Enter ONE symptom or complaint per section. Leave blank if you have fewer than 2 symptoms.

Symptom / Complaint:

Pain scale (1-10):

1 2 3 4 5 6 7 8 9 10

% of waking time:

5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

When did this symptom begin?

Result of motor vehicle collision?

Yes No

Did you have this symptom BEFORE the motor vehicle collision?

Yes No

If yes, intensity and frequency before accident:

What makes it WORSE? (check all that apply):

Other:

What makes it BETTER? (check all that apply):

Rest Ice Heat Stretching Exercise Massage Pain medication Muscle relaxers Nothing

Other:

Quality of symptom (check all that apply):

Sharp Dull Achy Burning Throbbing Piercing Stabbing Deep Nagging Shooting Stinging

Other:

Does it radiate?

Yes No

If yes, where?

Worse at certain times of day?

Morning Afternoon Evening Night Unaffected

Symptom 3

Enter ONE symptom or complaint per section. Leave blank if you have fewer than 3 symptoms.

Symptom / Complaint:

Pain scale (1-10):

1 2 3 4 5 6 7 8 9 10

% of waking time:

5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

When did this symptom begin?

Result of motor vehicle collision?

Yes No

Did you have this symptom BEFORE the motor vehicle collision?

Yes No

If yes, intensity and frequency before accident:

What makes it WORSE? (check all that apply):

Other:

What makes it BETTER? (check all that apply):

Rest Ice Heat Stretching Exercise Massage Pain medication Muscle relaxers Nothing

Other:

Quality of symptom (check all that apply):

Sharp Dull Achy Burning Throbbing Piercing Stabbing Deep Nagging Shooting Stinging

Other:

Does it radiate?

Yes No

If yes, where?

Worse at certain times of day?

Morning Afternoon Evening Night Unaffected

Symptom 4

Enter ONE symptom or complaint per section. Leave blank if you have fewer than 4 symptoms.

Symptom / Complaint:

Pain scale (1-10):

1 2 3 4 5 6 7 8 9 10

% of waking time:

5% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

When did this symptom begin?

Result of motor vehicle collision?

Yes No

Did you have this symptom BEFORE the motor vehicle collision?

Yes No

If yes, intensity and frequency before accident:

What makes it WORSE? (check all that apply):

Other:

What makes it BETTER? (check all that apply):

Rest Ice Heat Stretching Exercise Massage Pain medication Muscle relaxers Nothing

Other:

Quality of symptom (check all that apply):

Sharp Dull Achy Burning Throbbing Piercing Stabbing Deep Nagging Shooting Stinging

Other:

Does it radiate?

Yes No

If yes, where?

Worse at certain times of day?

Morning Afternoon Evening Night Unaffected

Additional Information & Acknowledgments

Is there anything else in your past medical history that is important to your care?

Authorization for Treatment: I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office of Chiropractic to provide me with chiropractic care, in accordance with this state's statutes. If my insurance will be billed, I authorize payment of medical benefits to Palmer Chiropractic for services performed.

Patient or Guardian Printed Name *

Date of Signature *

HIPAA Notice of Privacy Practices: By checking this box, I acknowledge that I have received, read, and understand the Palmer Chiropractic Notice of Privacy Practices.
📄 Read our HIPAA Notice of Privacy Practices →

I have read and acknowledge the HIPAA Notice of Privacy Practices *

PIP Exhaustion Policy: Once your PIP coverage has exhausted, Palmer Chiropractic will not bill your health insurance for further visits related to the MVA. We will require legal representation and hold bills awaiting settlement.
📄 Read our PIP Exhaustion Policy →

I have read and understand the PIP Exhaustion Policy *

Pregnancy Release: This certifies that to the best of my knowledge I am not pregnant and authorize x-ray evaluation. (Skip if male or not applicable)

I acknowledge the Pregnancy Release (if applicable)

By submitting this form you confirm all information is accurate and complete to the best of your knowledge. This form will be sent securely to Palmer Chiropractic.

Questions? Call us at (253) 854-7700

✅ Form Submitted Successfully!

Thank you! Your intake form has been received by Palmer Chiropractic. We will review it before your appointment. If you have questions, call us at (253) 854-7700.