1. Date of accident: ________________________

2. Was there head, neck, face, or jaw pain of any type before the accident?      Y        N

3. Did you lose consciousness?      Y        N

4. Did you go to a hospital?      Y        N

5. Did you go to a hospital in an ambulance?      Y        N

6. If you went to a hospital, what kind of X-rays were taken?: __________________________________________________________

7. If you went to a hospital, what treatment was done?: ________________________________________________________________

8. If you went to a hospital, was medication prescribed?      Y        N

9. If you went to a hospital, were you given a neck collar?      Y        N

10. In chronological order what types of doctors did you see before coming to this office and what treatments did you receive from that doctor?

Doctor's Name:

11. Do you have a lawyer?      Y        N

12. Who is your lawyer?: ________________________________________

13. Do you have a TMD or other headache?

14. Do you have a tootache of non-dental origin?

NOTE: Please make sure you bring a copy of your inurance claim form so we may know where to send it.