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Call : +1 (416) 249-8668

Email : info@trinityrehab.ca

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Looking for the Best Physical Rehab?

Call : +1 (416) 249-8668

Email :info@trinityrehab.ca

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About Us
Our Services
Patient Center
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Contact Us
FAQ

About Us
- Who We Are
- Our Team
- Careers
- Gallery
Services
- Core Services
- What We Treat
Patient Center
Contact Us
Blogs

Looking for the Best Physical Rehab?

About Us
Our Services
Patient Center
- Forms
Contact Us
FAQ

About Us
Our Services
Patient Center
- Forms
Contact Us
FAQ

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TPh. 416-249-8668, Fax. 416-249-5794, Email:info@trinityrehab.ca
1 723 Kipling Ave. Unit#9, Etobicoke, ON M9R4E1
www.Trinityrehab.ca

ACCIDENT PROFILE

Patient’s Name:

Date:

Were you working at the time of the accident?

Yes

No

Type of vehicle:

Date of Accident:

Amount of Damage:

Location of Accident:

How did the accident happen?

Were you wearing your seatbelt? Helmet if on bike or motorcycle?

Yes

No

Did you hit your head? If yes, where?

Yes

No

Where:

Were you able to exit the vehicle independently? If no, how did you exit?

Yes

No

how did you exit?

Did the ambulance arrive?

Yes

No

If yes, were you transported to hospital?

Did the airbags deploy?

Yes

No

Did you hit any other part of your body inside the vehicle? If yes, where?

Yes

No

Where:

Were you bleeding?

Yes

No

Did the police arrive?

Yes

No

Were you wearing your seatbelt? Helmet if on bike or motorcycle?

Yes

No

Did you lose consciousness? If yes, how long?

Yes

No

How long?:

Any nausea or vomiting after accident?

Yes

No

Was an accident report filed?

Yes

No

TREATMENT RECEIVED

DID YOU VISIT THE FOLLOWING?Please Select Both Checkbox.

Hospital

Family Physician

HOSPITAL

Date:

Name of Doctor:

Other:

Name / Location:

Findings:

Name of Doctor:

Prescribed Medications:

Family Physician

Date:

Name of Doctor:

Other:

Name / Location:

Findings:

Name of Doctor:

Prescribed Medications:

Have you received treatment at any other therapy clinic for this accident?

Yes

No

End Date:

Did you feel better after the treatment already received?:

*Name

Frequency:times / week

Translation needed:

Yes

No

Start Date:

Type of therapy:

Chiropractic

Physiotherapy

Massage o Exercises

Comments:

I hereby certify that I have read and understand the information recorded and verify that it is true and accurate.

Patient’s Signature:

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