Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Phone *

Primary

(###)

###

####

Phone

Secondary

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact's Name

First Name

Last Name

Contact's Phone

(###)

###

####

Are you covered by insurance? *

i.e.: Through work or privately, etc.

Yes

No

Who is the policy holder of this insurance?

Self

Spouse

Child

Other

Member's Name

If the policy holder is yourself, skip to Group No.

First Name

Last Name

Member's Birth Date

If the policy holder is yourself, skip to Group No.

MM

DD

YYYY

Address of MVA Insurance Company:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Adjuster Name

First Name

Last Name

Adjuster Phone

(###)

###

####

Fax

(###)

###

####

Policy Holder

First Name

Last Name

Date of Loss *

MM

DD

YYYY

You were: *

the Driver

a Passenger

on a Motorcycle

riding a Bicycle

a Pedestrian

You were seated:

Driver's seat

Front Passenger

Rear left

Rear middle

Rear right

Your vehicle was impacted: *

Front

Rear

Driver's side

Passenger's side

Not sure

Weather Conditions:

Clear

Wet

Snow

Icy

Did you hit your head?

Yes

No

Did you lose consciousness during or after the impact?

Yes

No

Were you able to get out/walk around unassisted?

Yes

No

Is your condition getting progressively worse?

Yes

No

This problem is:

Constant

Comes and goes

How does it feel?

Burning

Aching

Swelling

Sharp

Stiff

Tingling

Throbbing

Shooting

Dull

Other

Have you received treatment for this injury?

Yes

No

Are you currently receiving treatment from another health care professional?

Yes

No

Have your injuries during this accident affected your:

Work

Recreation/Sports

Daily life

Sleep

Neck pain and/or stiffness

Before collision

Immediately following

Currently experience

Shoulder or arm pain and/or stiffness

Before collision

Immediately following

Currently experience

Arm or Hand weakness and/or tingling

Before collision

Immediately following

Currently experience

Upper Back pain/stiffness

Before collision

Immediately following

Currently experience

Mid Back pain/stiffness

Before collision

Immediately following

Currently experience

Lower Back pain/stiffness

Before collision

Immediately following

Currently experience

Hip or Leg pain/stiffness

Before collision

Immediately following

Currently experience

Headaches

Before collision

Immediately following

Currently experience

Jaw, Tooth, or Ear pain

Before collision

Immediately following

Currently experience

Ringing in the ears (tinnitus), hearing loss

Before collision

Immediately following

Currently experience

Loss of co-ordination

Before collision

Immediately following

Currently experience

Dizziness

Before collision

Immediately following

Currently experience

Vision affected

Before collision

Immediately following

Currently experience

Difficulty swallowing and/or speaking

Before collision

Immediately following

Currently experience

Nausea and/or vomiting

Before collision

Immediately following

Currently experience

Numbness around your mouth

Before collision

Immediately following

Currently experience

Trouble concentrating and/or memory loss

Before collision

Immediately following

Currently experience

Sleep and/or personality changes

Before collision

Immediately following

Currently experience

Before collision

Immediately following

Currently experience

Have you had any:

Prior automobile accidents

Surgeries

Broken bones

Falls/Head injuries

Have you had any of the following conditions?

AIDS/HIV

Allergies

Anxiety/Depression

Arm/Shoulder Pain

Arthritis

Asthma

Bladder problems

Cancer

Chronic fatigue

Deafness

Diabetes

Digestion problems

Earache

Ear ringing

Epilepsy

Headaches/Migraines

Heart Disease

Hemorrhoids

Herniated disk

High blood pressure

Insomnia

Irregular cycle

Kidney problems

Leg pain

Low back pain

Neck pain

Osteoporosis

Poor circulation

Prostate problems

Rheumatoid Arthritis

Sciatica

Shingles

Sinus infection

Stroke

Thyroid problems

TMJ

Venereal disease

Vertigo/Dizziness

Do you have a family history of:

Cancer

Diabetes

Heart problems

High blood pressure

Are any of the following stressors a constant in your life:

Smoking

Alcohol

Coffee/Caffeine

High stress level

By agreeing, you confirm that: *

I confirm that the information I have provided in regards to my current condition and past health history are to the best of my knowledge. I also acknowledge that it is my responsibility to update the clinic in regards to any changes in my health condition. I authorize my insurance benefits be paid directly to the clinic. I acknowledge that any treatment fees not covered by MVA will be my responsibility, and I understand that I am financially responsible for any balance. I authorize Active Rehab Centre or insurance company to release any information required to process my claims. I also authorize Active Rehab Centre to release information regarding my medical condition to my family physician.

Agree

Disagree