Personal Injury Questionnaire

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: *
Should be Empty:

Personal Injury Questionnaire

Chief Complaints or Symptoms: