Services
Chiropractic
Neuropathy
Metabolic / Leaky Gut
Conditions Treated
Neck and Shoulder Pain
Wrist and Hand Pain
Back and Hip Pain
Knee and Foot Pain
Neuropathy
Gut Health
Massage Therapy
Patient Center
Online Forms
New Patient Intake Form
Auto Accident Form
What to Expect
Your First Visit
Phase 1: Relief Care
Phase 2: Corrective Care
Phase 3: Wellness Care
About Us
Meet the Doctor
Virtual Office Tour
Testimonials
FAQ's
Resources
3D Spine Simulator
Blog
Chiropractic Topics
About Chiropractic Care
What is Chiropractic
How Does it Work
Who is Chiropractic For
Vertebral Subluxation
Wellness Resources
Common Conditions Treated
Auto Accident Injuries
Back and Shoulder Pain
Body Pain
Chronic Condition Relief
Conditions Affecting Women
Headaches
Herniated Discs
Improved Health
Pediatric Ailments
Repetitive Use Injuries
Respiratory Function
Health & Wellness
Healthy Thinking
Get Positive
Relaxation Techniques
Life in Motion
Wellness Lifestyle Tips
Treat Yourself Well
Treat Others Well
Eat Well
Wellness Essentials
At Home
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Exercise
Nutrition
What You Wear
Wellness Perspectives
Mental
Spiritual
Social
Physical
Therapies & Techniques
Techniques
Therapies
Newsletter Library
Back, Body & Joint Pain
Healthy Tips
Exercise & Fitness
Injury Rehab & Prevention
Kid's Health
Illness Prevention
Chronic Conditions
Nutrition & Healthy Eating
Breaking Bad Habits
Senior Health
Weight Loss
Pregnancy & Parenting
Wellness
Mind-Body Connection
Stress & Anxiety
Life-Work Balance
Staying Young
Staying Motivated
Wellness4Kids
Contact
Schedule Appointment
Hanley Chiropractic Healthcare Inc
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New Patients Schedule Here
Existing Patients Schedule Here
Services
Chiropractic
Neuropathy
Metabolic / Leaky Gut
Conditions Treated
Neck and Shoulder Pain
Wrist and Hand Pain
Back and Hip Pain
Knee and Foot Pain
Neuropathy
Gut Health
Massage Therapy
Patient Center
Online Forms
New Patient Intake Form
Auto Accident Form
What to Expect
Your First Visit
Phase 1: Relief Care
Phase 2: Corrective Care
Phase 3: Wellness Care
About Us
Meet the Doctor
Virtual Office Tour
Testimonials
FAQ's
Resources
3D Spine Simulator
Blog
Chiropractic Topics
About Chiropractic Care
What is Chiropractic
How Does it Work
Who is Chiropractic For
Vertebral Subluxation
Wellness Resources
Common Conditions Treated
Auto Accident Injuries
Back and Shoulder Pain
Body Pain
Chronic Condition Relief
Conditions Affecting Women
Headaches
Herniated Discs
Improved Health
Pediatric Ailments
Repetitive Use Injuries
Respiratory Function
Health & Wellness
Healthy Thinking
Get Positive
Relaxation Techniques
Life in Motion
Wellness Lifestyle Tips
Treat Yourself Well
Treat Others Well
Eat Well
Wellness Essentials
At Home
At Work
Exercise
Nutrition
What You Wear
Wellness Perspectives
Mental
Spiritual
Social
Physical
Therapies & Techniques
Techniques
Therapies
Newsletter Library
Back, Body & Joint Pain
Healthy Tips
Exercise & Fitness
Injury Rehab & Prevention
Kid's Health
Illness Prevention
Chronic Conditions
Nutrition & Healthy Eating
Breaking Bad Habits
Senior Health
Weight Loss
Pregnancy & Parenting
Wellness
Mind-Body Connection
Stress & Anxiety
Life-Work Balance
Staying Young
Staying Motivated
Wellness4Kids
Contact
Schedule Appointment
New Patients Schedule Here
Existing Patients Schedule Here.
Services
Chiropractic
Neuropathy
Metabolic / Leaky Gut
Conditions Treated
Neck and Shoulder Pain
Wrist and Hand Pain
Back and Hip Pain
Knee and Foot Pain
Neuropathy
Gut Health
Massage Therapy
Patient Center
Online Forms
New Patient Intake Form
Auto Accident Form
What to Expect
Your First Visit
Phase 1: Relief Care
Phase 2: Corrective Care
Phase 3: Wellness Care
About Us
Meet the Doctor
Virtual Office Tour
Testimonials
FAQ's
Resources
3D Spine Simulator
Blog
Chiropractic Topics
About Chiropractic Care
What is Chiropractic
How Does it Work
Who is Chiropractic For
Vertebral Subluxation
Wellness Resources
Common Conditions Treated
Auto Accident Injuries
Back and Shoulder Pain
Body Pain
Chronic Condition Relief
Conditions Affecting Women
Headaches
Herniated Discs
Improved Health
Pediatric Ailments
Repetitive Use Injuries
Respiratory Function
Health & Wellness
Healthy Thinking
Get Positive
Relaxation Techniques
Life in Motion
Wellness Lifestyle Tips
Treat Yourself Well
Treat Others Well
Eat Well
Wellness Essentials
At Home
At Work
Exercise
Nutrition
What You Wear
Wellness Perspectives
Mental
Spiritual
Social
Physical
Therapies & Techniques
Techniques
Therapies
Newsletter Library
Back, Body & Joint Pain
Healthy Tips
Exercise & Fitness
Injury Rehab & Prevention
Kid's Health
Illness Prevention
Chronic Conditions
Nutrition & Healthy Eating
Breaking Bad Habits
Senior Health
Weight Loss
Pregnancy & Parenting
Wellness
Mind-Body Connection
Stress & Anxiety
Life-Work Balance
Staying Young
Staying Motivated
Wellness4Kids
Contact
Schedule Appointment
Home
>
Patient Center
>
Online Forms
>
Auto Accident Form
Auto Accident Form
Automobile Accident Details
First Name
*
Last Name
*
Date
Email
*
Phone
*
Date of accident
Time of accident: _____ AM/PM
Time of accident:
Dawn
Daylight
Dusk
Night
Location (nearest intersection with road/street direction)
Accident description:
Did the car go off the road?
Yes
No
Length of time you were in the car before accident: ___ (min/hrs)
Body parts that were struck during the collision:
Your position in the car:
driver
passenger (which seat)
front
rear
Your status before the accident (may answer more than one)
tired
asleep
awake
reclined in the seat
rotated in the seat
seat belt on
seatbelt of
shoulder harness on
shoulder harness of
What was the posted speed limit (mph)
How fast were you traveling before impact (mph)
Were citations given
Yes
No
Reason citation was given
Was an accident/injury report filed
Yes
No
Accident was reported to
Any witnesses?:
Yes
No
Traffic conditions:
normal
good
heavy
congested
rush hour
Where was your vehicle impacted:
front
rear
left side
right side
Make model and year of your vehicle
Make model and year of the other vehicle
Weather conditions
normal
foggy
icy
poor visibility
raining
snowing
windy
Location you were taken after the accident:
home
hospital
emergency room
minor emergency center
other
If Other, please describe
Were you hospitalized (admitted overnight or longer)
Yes
No
What tests (ie X-Rays, MRI etc.) and treatments (ie. drug, surgery etc) did you receive
Functional Assessment
Have you noticed limitations using your
neck
shoulders
arms
hands
back
feet
bowel/bladder
other
Do you have pain when:
lifting over
sitting over
bending
standing
walking
climbing
reaching
squatting
twisting
crawling
If lifting, then Ibs?
If sitting, then min/hrs?
Submit
Thank you for taking the time to fill out this form.
Our Location
Find Us On The Map
--
mi
Address
955 Factory Rd
Beavercreek, OH 45434
Contact Information
(937) 426-4545
