Motor Vehicle Collision Intake Form
COLLISION INFORMATION
Full Name
*
Today's Date
*
-
Month
-
Day
Year
Date
Where did the collision occur:
Street
Street Address Line 2
City
State / Province
Postal / Zip Code
Date when collision occurred:
-
Month
-
Day
Year
Date
Did the collision occur in the AM or PM:
AM
PM
Was the road:
Dry
Wet
Snowy
Icy
Were you the:
Driver
Front middle passenger
Front right passenger
Back left
Back middle
Describe what happened with the accident:
CRASH DETAILS
If driving, were both hands on the wheel at impact?
Yes
No
If passenger, did your hands brace yourself?
Yes
No
Did you have your seat belt and shoulder strap on?
Yes
No
Was your seat up at the time of impact?
Yes
No
Were you wearing a bulky coat or slippery pants?
Yes
No
Did the seat belt engage?
Yes
No
Did the airbag engage?
Yes
No
Did you hit the dash, steering wheel or window?
Yes
No
Did you know you were going to be hit?
Yes
No
Did you brace yourself with hands or feet?
Yes
No
If driving, was your foot on the brake at impact?
Yes
No
Was your head turned at impact?
Yes
No
Were you leaning forward?
Yes
No
Did your glasses fly-off at impact?
Yes
No
Was your body turned at the moment of impact?
Yes
No
Did you get hit into another car, tree, railing, etc?
Yes
No
Any damage or marks on your vehicle, the vehicle that hit you, or another object that was hit?
Yes
No
What part of the vehicle was hit?
What make and model of vehicle were you in?
The make and model of the other vehicle?
What kind of seat were you in?
Bucket
Bench
Fabric
Leather/Vinyl
Did the car have headrests?
Yes
No
Did you hit your head on the headrest?
Yes
No
Did you hit your head on the back window if in a small truck?
Yes
No
Was the headrest positioned _____________ the center of your head:
below
level with
above
Did your head hurt after the collision?
Yes
No
Did your TMJ/jaw hurt after the collision?
Yes
No
How soon after the collision did you notice any pain?
Did the crash affect:
dizziness
memory
concentration
headaches
balance
nightmares
breathing
fatigue
irritability
ability to read
ability to listen
appetite
nausea
vision
Is there anything else about the collision or your symptoms that you would like us to know?
PROVIDERS SEEN
List all providers seen since injury occurred:
1. Clinic/Doctor/Hospital Name
Clinic/Doctor/Hospital Name
Street Address Line 2
City
State / Province
Postal / Zip Code
2. Clinic/Doctor/Hospital Name
Clinic/Doctor/Hospital Name
Street Address Line 2
City
State / Province
Postal / Zip Code
3. Clinic/Doctor/Hospital Name
Clinic/Doctor/Hospital Name
Street Address Line 2
City
State / Province
Postal / Zip Code
4. Clinic/Doctor/Hospital Name
Clinic/Doctor/Hospital Name
Street Address Line 2
City
State / Province
Postal / Zip Code
5. Clinic/Doctor/Hospital Name
Clinic/Doctor/Hospital Name
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have pictures of your vehicle?
Yes
No
Where is your vehicle being repaired?
Do you have a copy of the police report?
Yes
No
Name of your Attorney if you have one:
Name of Your Car Insurance Company:
Your Health Insurance Company:
Name of the Other Drivers Car Insurance if Applicable:
Car Insurance Medical Claim Number if Applicable:
Please check the box below when you are ready to submit.
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