MVA Questionnairre

Name

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Motor Vehicle Accident (MVA) Questionnaire

Please fill this out to the best of your ability!
Date of Accident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What state did the accident occur in?
Were you the driver or a passenger?
Where in the car were you?
Where were you looking? Did you see it coming?
Did you hit your head? Or lose consciousness?
What part of the car was hit?
Was anyone else in the car? How are they?
Were you wearing your seatbelt?
What kind of car were you in?
What kind of car hit you?
How fast were you going?
How fast were they going?
Did the airbags deploy in either car? Which ones?
How much damage to your car? Was it totaled?
How much damage to the other car? Was it totaled?
When did the pain start? (Immediately, later that day, etc.)
Did you seek medical care at the time of the accident?
If yes, where did you go?
Did they do any imaging? (X ray, MRI, CT, etc.)
What type of treatment did you receive? (ice, medication, etc.)
Please explain any other treatment you received for injuries sustained in the accident