This is a confidential intake form for what we call a preliminary screening.

We are screening you to see if you suffered a serious spinal injury as the result of your motor vehicle accident.

If the doctor thinks you may have a ligament instability in your neck or lower back, we will proceed with a screening examination followed by a specialty x-ray.

IT TAKES APPROXIMATELY 10 MINUTES TO COMPLETE THIS FORM

Confidential    Screening    Examination
Specialty End-Range Stress Test X-ray Screen
In collaboration with the Ontario Research Medical Group,
a sub-division of Better Call Doc Inc.
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Date of Accident

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S C R E E N I N G    Q U E S T I O N S P E R T A I N I N G   T O   Y O U R   A C C I D E N T
Please check below ONLY if the answer to the question is YES
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General
Gastro-intestinal
Cardio-vascular
Genito-urinary
Skin
Respiratory
For women only
Have you eve been diagnosed with:
Upload your medical x-ray/MRI/CT reports

Thanks for submitting. The doctor will review your records. Your medical information complies with the provincial information privacy act (HIPPA)