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Need Advice
Accident Checklist


Complete the form below. 
When you are finished, click the Submit button
at the end of this form
to send your questions to us.

Type of Accident or Injury.

Date of Accident or Injury.

What Type of Services Do You Need?  
Check ALL that apply.
If you do not know,
Click Here

Spinal Impairment Rating
Convert Whole Person Impairment to Regional Spine Impairment
Functional Capacity Assessment
Spinal Disability Evaluation
Chronic Pain Syndrome Rating
Independent Medical Exam (IME) Second Opinion
Work Restriction Documentation
Lost Pre-Injury Capacity Documentation
Scoliosis Impairment Rating
Regional Scoliosis Impairment Rating
Case Review - File Review
I Don't Know

Where is your pain?
Please check the following boxes if they apply.
You can choose more than one box.

Neck  Mid-Back  Low Back  Arms and Legs

Have you been to a doctor for
this condition before?
Yes No

Did you ever have an Impairment Rating for
this accident?
Yes No

Are you currently being represented by an
attorney for this accident?
Yes  No

Type in your question's and the related facts
of the accident below.


City, State, Zip Code

I understand that the information I have given on this form is true and correct.  

I also understand that it is illegal to give false and/or fraudulent facts about 

my condition to this office.  If at any time it is determined that I have given fraudulent 

information regarding a medical or non-medical condition regardless of the intent,

I understand that I will be prosecuted to the fullest extent of the law under federal,

state and local statutes.

I agree with the above Disclaimer

Yes No


Contact Information

Dr. Gerald R. Lapinsky, DC, CSDE, DABDA
Chiropractic Physician
Certified Spinal Disability Evaluator
Senior Diplomate American Board of Disability Analysts

Postal address
P.O. Box 10185  Phoenix, AZ  85064-0185



DISCLAIMER: The information contained on this web site is not intended to alleviate, improve, maintain or cure medical and/or non-medical condition(s).  This material does not constitute medical and/or legal advice.  This web site is intended for informational purposes only.   Consult a licensed physician for specific recommendations and treatment.

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