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Personal Injury Questionnaire - bbrombergchiropracticbbcomb 2025

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The document is a Personal Injury Questionnaire from Bromberg Chiropractic Office, designed to collect confidential information from patients involved in accidents. It includes sections for personal details, accident specifics, injury descriptions, medical history, and insurance information to assist in determining chiropractic care needs and processing insurance claims.

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Click ‘Get Form’ to open the Personal Injury Questionnaire in the editor.
Begin by filling in your personal details at the top of the form, including your name, sex, date, address, and contact information. Ensure accuracy as this information is crucial for your chiropractic care.
Proceed to section 1 and provide details about the accident, including the date, time, and location. This context helps in understanding your situation better.
In section 2, select the type of accident you experienced. You can check multiple options if applicable.
Section 3 requires a detailed explanation of how the accident occurred. Use clear language to describe events leading up to it.
For auto collision specifics in section 4, indicate which part of your vehicle was impacted and where you were seated during the incident.
Continue through sections 5 to 11 by providing information on injuries, treatments received, and any previous similar conditions. This comprehensive data aids in tailoring your treatment plan.
Finally, complete the insurance information section accurately to facilitate claims processing.

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