📍 7100 SW Hampton St, Suite 121, Tigard, OR 97223 📞 Call for Free Consultation: (503) 512-5359

Our Doctors ▾

Dr. Lawrence K. Nelson, DC, DACNB
Dr. Adam Hernandez, DC
Dr. Walter Trapp, DC
Rocco Manziano, L.Ac., CAA

Services ▾

Functional Neurology
Gentle Cervical Chiropractic
Soft-Tissue & Massage Therapy
Low-Level Cold Laser Therapy
Neuro-Acupuncture
Recovery & Lifestyle Coaching
Medical Thermography

Home Exercises ▾

Morning Routine
Stance, Integration & Spot Exercises
Phase 1: Exercise Ball
Phase 2: Foam Pad
Symptom Tracker

Patient Forms Testimonials Request Appointment

Appointment Phone Call Request

Concussion & Whiplash Clinic

7100 SW Hampton St, Suite 121, Tigard, OR 97223 | Phone: (503) 512-5359

1. Patient Information

Full Name *

Date of Birth *

Biological Sex

Phone Number *

Email Address *

Street Address

City, State, Zip

2. Incident & Injury History

Date of Injury / Incident *

Type of Incident

Briefly Describe How the Injury Occurred

Do you have an open Auto or Workers Comp claim?

Yes No

3. Current Symptoms Checklist

Check all symptoms you are currently experiencing:

Headaches / Migraines Neck Pain or Stiffness Dizziness / Unsteadiness Brain Fog / Memory Loss Sensitivity to Light Sensitivity to Noise Nausea or Vomiting Trouble Sleeping Extreme Fatigue Ringing in Ears (Tinnitus)

4. Clinic Policy & Consent

I certify that the information provided above is complete and accurate. I authorize Concussion & Whiplash Clinic specialists to perform neurological assessments and recommended treatments.

Electronic Signature (Full Name) *

Today's Date *

© Concussion & Whiplash Clinic (ConcussionPDX.com). All rights reserved.