Personal Injury Questionnaire
Full Name
*
Address:
*
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date of Accident
*
/
Month
/
Day
Year
Auto Insurance
*
Insurance Adjuster
*
Claim Number
*
Insurance Address
*
Insurance Phone
*
Was there a police report filed?
Yes
No
Where did the accident happen?
*
Describe the accident in your own words:
*
What was your position in the car?
*
Driver
Passenger
Where were your hands on the steering wheel?
*
Left
Right
Both
Where were you sitting?
*
Front
Right Rear
Left Rear
Did your vehicle strike another vehicle?
*
Yes
No
Was your vehicle struck by another vehicle?
*
Yes
No
Angles of Impact (first collision)
*
Front
Back
Left
Right
Angles of impact (second collision)
Front
Back
Left
Right
Were you wearing a seat belt?
*
Yes
No
Did you brace for impact?
*
Yes
No
I braced with my hands
I braced with my feet
Which way were you facing at the time of impact . . .
*
Straight
Ahead
Left
Right
Did your body or any body part strike anything in the vehicle at the time of impact?
*
Yes
No
Please specify body part and part of vehicle of impact
*
Did the seat back bend or break?
*
Yes
No
Immediately following the accident, how did you feel? (check all that apply)
*
Unconscious
Nervous
Nauseous
Upset
Weak
Dizzy
Disoriented
Did you go to the hospital?
*
Yes
No
Were you admitted to the hospital?
*
Yes
No
How long were you admitted?
*
When were you admitted to the hospital?
*
How did you get to the hospital?
*
Ambulance
Police Car
Private Transportation
Name of Hospital:
*
Attended by Dr.
*
What treatment was given? (check all that apply)
*
None
placed in a cervical collar
x-rays
given stitches
bandaged
Given pain medication
Given instructions regarding concussions
Given instructions regarding sprains and strains
Physical therapy
Instructed to call a Orthopedic Surgeon
Instructed to call a private physician
Referred to this office for treatment
Have you seen any other doctor as a result of this accident?
*
Yes
No
Doctor's names
*
Chief Complaints or Symptoms:
Neck pain
*
Yes
No
Check off any areas that your pain runs into from the neck (if applicable)
*
right shoulder
right arm
right forearm
right hand
left shoulder
left arm
left forearm
left hand
Do you suffer with any of the below symptoms since the accident?
*
Headache
Migraine Headache
Upper Back Pain
Ringing in the ears
Blurry vision
Wrist pain
Jaw pain
Additional symptoms since accident:
*
Dizziness
Nervousness
Fatigue
Anxiety
Depression
Excessive irritability
Fear of driving in a car
Loss of concentration
Jaw clenching
Grinding of teeth at night
Nightmares
Difficulty sleeping at night
Low Back pain
*
Yes
No
Select the areas of radiation from the low back (if applicable)
*
left buttocks
left thigh
left knee
left foot
right knee
right foot
right buttock
right thigh
Hip pain
*
Left
Right
Bilateral
None
Knee pain
*
Left
Right
Bilateral
None
Foot Pain
*
Left
Right
Bilateral
None
Numbness:
*
Left Hand
Left Upper Arm
Right Hand
Right Upper Arm
Left Foot
Left leg
Right Foot
Right Leg
None
Additional Symptoms/Complaints
Have you lost any time from work due to your injuries?
*
Yes
No
Type of employment:
*
Have you had previous injuries from an auto accident?
*
Yes
No
Description of previous injuries:
*
Is there any residual pain for the previous injuries?
*
Yes
No
How much better did you feel prior to your current condition? (Example 100%, 80% etc.)
*
Have you had previous auto accidents?
*
Yes
No
Description of previous accident:
*
Submit
Should be Empty: