4550 E. Bell Road, Ste. 152 Phoenix, AZ 85032 (602) 258-9663
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Arizona Sports Chiropractic and Wellness Center
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PATIENT INFORMATION

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INSURANCE

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PHONE NUMBERS

IN CASE OF EMERGENCY, CONTACT

ACCIDENT INFORMATION

Is this condition due to an accident?
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Type of accident
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PATIENT CONDITION

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HEALTH HISTORY

What treatment have you already received for your condition?
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Prosthesis
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Injuries/Surgeries you have had
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PATIENT INFORMATION

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Time of Accident
Were you the

ACCIDENT SITE

Driving Conditions

IMPACT

Did your car impact another vehicle?
Did your car impact a structure?
Did any part of your body strike anything in the vehicle?
At the time of impact were you:
Were both your hands on the steering wheel?
Which hand was on the wheel?
Was your foot on the brake?
Which foot was on the brake?
Were you:

OTHER VEHICLE

POLICE

Did the police come to the accident site?
Were there any witnesses?
Was a police report filed?
Was a traffic violation issued?

PATIENT CONDITION

Were you unconscious immediately after the accident?

TREATMENT

Did you go to the hospital?
When did you go?
How did you get to the hospital?

SYMPTOMS/INJURIES

Have you been able to work since this injury?
Prior to the injury, were you able to work on an equal basis with others your age?
If you have had any of the following symptoms since your injury, please check:
Is this condition getting progressively worse?

Rate the severity of your pain on a scale from 1(least pain) to 10 (severe pain)

Does it interfere with you:
Activities or movements that are painful to perform:

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    Arizona Sports Chiropractic & Wellness

    Dr. Wood and his team have been committed to bringing the North Phoenix community better Chiropractic and health and a better way of life for over 25 years.

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    Our Services

    Dry Needling

    Chiropractic Manipulation

    Functional Movement Evaluations

    Custom Rehab Programs

    DTS-Spinal Decompression

    Soft Tissue Treatment

    Supportive Therapies

    Arizona Neurofeedback

    Sports Physicals

    Massage Therapy

    Manipulation Under Anesthesia

    Virtual Consulting

    Find Us

    4550 E. Bell Road, Ste. 152
    Phoenix, AZ 85032

    Call Us

    (602) 258-9663

    New Patients

    New Patient Information

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