Bioenergetic Wellness Center
32156 Castle Court, #108
EVERGREEN, CO 80439-7010
(720) 722-2188
info@bioenergeticwellnesscenter.com
Automobile Accident History
First Name
Last Name
Birthdate
Date of Accident
Time Accident Occurred
AM
PM
Were you taken to the hospital?
Yes
No
Did you stay in the hospital as a patient?
Yes
No
Name of the doctor who treated you after the accident?
If X-rays were taken, which ones?
Head
Shoulders
Neck
Back
Arm(s)
Leg(s)
Pelvis
Feet
Hand(s)
The following questions pertain to you, the patient, and the vehicle you were in.
Were you unable to work/attend school due to your injuries? (Please enter the date range)
Have you retained an attorney?
Yes
No
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