Irving Park Chiropractic Center - Fill Out Paperwork Online

Address

Email Address

Please briefly describe how the accident happened:

Did you go to the hospital or urgent care after the accident? Yes No

If yes, what hospital or urgent care? Were any scans taken? Yes No

If yes, were there any findings?

Was there any bruising to your body due to the accident? Yes No

If so, where?

Are you taking any pain medication due to the accident? Yes No

If so, what is the medication?

Did you miss any work due to the accident? Yes No

If yes: What is your job?

How much time have you missed?

History of spinal surgeries? Yes No

If yes, list year and type:

History of cancer? Yes No

If yes, kind, diagnosis date, and remission status:

Patient Demographics