Kaneohe Family Chiropractic
46-001 Kamehameha Hwy #419B
Kaneohe, HI 96744
(808) 234-5535
Automobile Accident History
First Name
Last Name
Date of Accident
Time Accident Occurred
Were you taken to the hospital?
Did you stay in the hospital as a patient?
Name of the doctor who treated you after the accident?
If X-rays were taken, which ones?
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?