Comprehensive Chiropractic Incident Report Form Template

Patient Information

• Full Name: _________________________
• Date of Birth: //______
• Patient ID: _________________________
• Contact Number: _____________________

Incident Details

• Date of Incident: //______
• Time of Incident: : AM/PM
• Location in Practice: ________________

Type of Incident (check all that apply)

□ Treatment-related □ Fall/Slip □ Equipment malfunction □ Patient complaint □ Other: ___________________________

Description of Incident

Detailed account of what occurred:

Immediate Actions Taken

1. First response measures: ____________
2. Staff members involved: ____________
3. Emergency services called? □ Yes □ No

Witness Information

• Name(s): _________________________
• Contact Details: ___________________

Clinical Assessment

Symptoms/Injuries Reported

Examination Findings

Follow-up Actions

□ Patient referred to: ________________ □ Follow-up appointment scheduled □ Insurance carrier notified □ Risk management procedures initiated

Report Completed By

• Name: ____________________________
• Position: _________________________
• Signature: ________________________
• Date: //______

Administrative Use Only

• Report Number: ____________________
• Review Date: //______
• Actions Required: __________________