COLLISION INFORMATION
Full Circle Health - 110 Four Seasons Shopping Ctr St. Louis MO 63017
Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where did the collision occur:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date when collision occurred
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Was the road:
*
Dry
Wet
Snowy
Icy
Where you the:
*
Driver
Front middle passenger
Front right passenger
Back left
Back middle
Back right
Describe what happened:
*
Back
Next
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
Where 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?
*
What was the other vehicles make and model?
*
What kind of seat were you in?
*
Bucket
Bench
Fabric
Leather/Vinyl
Did the car have headrests?
*
Yes
No
Was the headrest positioned:
*
below the center of your head
above the center of your head
at level with the center of your head
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 (select all that apply):
*
dizziness
memory
concentration
headaches
balance
nightmares
breathing
fatigue
irritability
ability to read
appetite
nausea
vision
Is there anything else you want us to know?
*
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PROVIDERS SEEN
List all providers seen since injury occurred:
Clinic/Doctor/Hospital Name
*
City
*
Clinic/Doctor/Hospital Name
*
City
*
Clinic/Doctor/Hospital Name
*
City
*
Clinic/Doctor/Hospital Name
*
City
*
Clinic/Doctor/Hospital Name
*
City
*
Do you have pictures of your vehicle?
*
Yes
No
Do you have a copy of the police report?
*
Yes
No
Where is it being repaired?
*
Name of your Attorney if you have one:
*
Name of Your Car Insurance Co:
*
Your Health Ins. Co:
*
Name of the Other Divers car Insurance if applicable
*
Submit
Should be Empty: