Auto Accident Intake
Name:
Date:
-
Month
-
Day
Year
When did the accident occur?
-
Month
-
Day
Year
Which were you?
Driver
Front Passenger
Rear Passenger
Pedestrian
Your vehicle:
Car
Truck
SUV
Vehicle that hit you:
Car
Truck
SUV
Occurred at:
Intersection
Parking Lot
Freeway
Town
What direction were you headed?
Northbound
Eastbound
Westbound
Southbound
At impact, was your vehicle?
Parked
Stopped
Slowing
When?
Dawn
Morning
Afternoon
Dusk
Night
Driving conditions:
Normal
Dry
Stormy
Wet
Wind
Where was the impact?
Driver side
Passenger side
Front
Rear
Did you hit another car or object after 1st impact?
No
Another Car
Object
Body hit the vehicle interior:
Head
Face
L / R Shoulder
Chest
L / R Knee
Where were you looking at time of impact?
Fwd
Rear
Left
Right
Up
Down
Driver: which hands were on the steering wheel?
Both
Right
Left
None
Driver: which foot was on the brake?
Right
Left
Both
Neither
Head restraint position:
Middle
High
Low
No Head Restraint
Air bag deployed:
Steering Wheel
Driver Side
Passenger Side
None
Were you wearing a seat belt?
Yes
No
Child Restraint
What doors did not open?
Rear Hatch
Trunk
Front Driver Side
Front Passenger
Rear Driver Side
Rear Passenger Side
All doors opened freely
Hospitalized:
Abrazo West
Banner Estrella
Dignity
Urgent Care
Other
Treatment:
Medications
X-Ray
CT Scan
Neck Braces
Other
Medications:
Ibuprofen
Flexeril
Oxycodone
Percocet
Tyleno
Advil
Aleve
Other
Did you see your PCP?
Yes
No
When?
Dr.
Home care done:
Over the Counter Meds
Ice
Heat
Rest
Avoid Activity
Followed instructions of ER
Followed instructions of PCP
Occupation:
Missed Days:
Light Duty:
Yes
No
How did you feel before your accident?
Pain
No Pain
Do you have any serious pre-existing neck or back conditions?
Yes
No
Have you been in a previous car accident?
Yes
Never
When?
Were you hurt?
Yes
No
Received medical care?
Yes
No
Released pain free?
Yes
No
Daily Habits:
0 = none 1 = a little 2 = moderate 3 = a lot
Smoking:
0
1
2
3
Alcohol:
0
1
2
3
Exercise:
0
1
2
3
Dominant Hand:
Left
Right
Please Select Those Where You Are Having Symptoms?
Neck Pain
Low Back Pain
Headache
Left / Right Blurry Vision
Left / Right Shoulder Pain
Left / Right Hand Pain
Left / Right Hip Pain
Left / Right Foot Pain
Left / Right Rib Pain
Left / Right Arm Numb
Left / Right Leg Numb
Vertigo
Left / Right Ear Ringing
Left / Right Elbow Pain
Left / Right Arm Pain
Left / Right Knee Pain
Left / Right Leg Pain
Chest Pain
Mid Back Pain
Left / Right Sciatica
Short Term Memory Loss
Left / Right Jaw Pain
Left / Right Wrist Pain
Stomach Pain
Left / Right Ankle Pain
Left / Right Leg Cuts/Bruise
Left / Right Arm Cuts/Bruise
Pain Level:
3
4
5
6
7
8
9
10
Type:
Aching
Sharp
Cramping
Radiating
Stiff
Spasm
Burning
Tight
Tingling
Freq:
Constant
Worse at night
Frequent
Worse in Afternoon
Worse in Morning
Which Activities Aggravate Your Condition?
Back Movement
Neck Movement
Sneezing
Bending
Reaching
Standing
Coughing
Sex
Using Restroom
Driving
Sitting
Walking
House Chores
Sleeping
Yard Work
Lifting
Other
Please Select Any Recent Change in the Following Functions?
Absence of Smell
Fainting
Mouth Bleeding
Anxiety
Fatigue
Mouth Sores
Appetite Change
Forgetfulness
Nail Change
Blue Arms
Frequent Urination
Night Sweats
Blue Legs
Hair Change
Nose Bleeds
Change in Taste
Hearing Trouble
Nose Pain
Cold Intolerance
Heart Murmurs
Painful Urination
Concentration
Heat Intolerance
Palpitations
Convulsion
Impotence
Rash / Redness
Cough Wheezing
Inability to Urinate
Swollen Arms
Depression
Itching
Swollen Legs
Difficulty Breathing
Memory Loss
Tremors
Digestive Changes
Mood Swing
Weight Changes
Ear Pain
For Females:
Are you pregnant?
Not Sure
Yes
No
Breast Lump
Discharge of Breast
Vaginal Bleeding
Breast Pain
Irregular Menstruation
Vaginal Pain
Breast Red/Itching
Family Illness:
Father
Mother
Sibling
Illness?
Please Select Any of the Following Disorders that Apply to You:
Allergies
Hay Fever
Rheumatic Fever
Arthritis
Heart Disease
STD
Asthma
High Blood Pressure
Scoliosis
Bone Fracture
Kidney
Sinusitis
Cancer
Low Blood Pressure
Spinal Disc Disease
Diabetes
Multiple Sclerosis
Thyroid
Emotional Disorder
Polio
Tuberculosis
Epilepsy
Prostate
Ulcer
HIV
Surgeries and Medications:
Signature:
Clear
Please verify that you are human
*
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