INTAKE SPECIALIST CASE TYPE Tractor Trailer AccidentsCar AccidentsMotorcycle AccidentsNursing Home NeglectSlip & FallSocial Security DisabilityWorkers’ CompDog BitesMedical NegligenceCruise Ship Injuries CALLER NAME RELATION TO CLIENT CLIENT NAME: CLIENT ADDRESS: State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew Hampshire Date of birth: Gender: MF HOME TELEPHONE#: MOBILE #: ALTERNATIVE #: MOBILE PROVIDER: EMAIL: ACCIDENT DATE: ACCIDENT TIME: : AMPM ACCIDENT LOCATION DESCRIPTION: ACCIDENT LOCATION AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustralia State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew Hampshire ACCIDENT COMPANION (S): DESCRIPTION OF ACCIDENT: DO YOU HAVE A COPY OF THE ACCIDENT REPORT? YesNo CRASH REPORT #: PROPERTY INSURANCE: Company: Policy: SCENE PICS TAKEN: CLIENT LEFT SCENE BY INJURIES: LOWER BACK PAINUPPER BACK PAINSHOULDER PAINNECK PAINHEADACHESNAUSEADIFFICULTY SLEEPINGANXIETYCUTS AND BRUISESBROKEN BONESLOSS OF FEELING IN PART OF BODYDIFFICULTY BREATHINGIMPAIRED VISIONMEMORY LOSSOTHER DESCRIPTION OF ACCIDENT INJURIES: STATUS OF MEDICAL TREATMENT: NONE ER VISIT MEDICAL DOCTOR SURGEON CHIROPRACTOR ACUPUNCTURIST PHYSICAL THERAPIST OTHERS MEDICAL TREATMENT FACILITY LOCATION: MISSED TIME FROM WORK BECAUSE OF THE INJURY? YESNO NUMBER OF MISSED WORK DAYS: DESCRIPTION OF ANY PRIOR INJURIES: REFERRAL SOURCE: ADDITIONAL INFORMATION:
