VEHICLE ACCIDENT INFORMATION
PATIENT INFORMATION
Date
-
Month
-
Day
Year
Date
Patient Name
First Name
Last Name
Date of Accident
-
Month
-
Day
Year
Date
Time of Accident
Hour Minutes
AM
PM
AM/PM Option
Please describe the accident in your own words:
Were you the:
Driver
Front Passenger
Rear Passenger
Pedestrian
How many people were in the accident vehicle?
ACCIDENT SITE
Road/Street Name
City/State
Nearest intersection with road/street
Driving conditions
Dry
Wet
Icy
Other
Which direction were you headed?
Speed you were traveling?
VEHICLE
Make and model of vehicle you were in:
Were you wearing a seatbelt?
Yes
No
If yes, what type?
Shoulder
Lap
Was vehicle equipped with airbags?
Yes
No
If yes, did it/they inflate properly?
Yes
No
Did your seat have a headrest?
Yes
No
If yes, what was the position of the headrest?
Low
Mid position
High
OTHER VEHICLE
If applicable
Make and model of other vehicle
Which direction was other vehicle headed?
Speed other vehicle was traveling
IMPACT
Did your car impact another vehicle?
Yes
No
Did your car impact a structure?
Yes
No
If yes, explain:
Was impact from:
Front
Rear
Left
Right
Other
At the time of impact were you:
Looking straight ahead
Looking to the left
Looking to the right
Looking down
Looking up
Were both hands on the steering wheel?
Yes
No
If no, which hand was on the wheel?
Right
Left
Was your foot on the brake?
Yes
No
If yes, which foot was on the brake?
Right
Left
Were you:
Surprised by impact
Braced for impact
POLICE
Did the police come to the accident site?
Yes
No
Were there any witnesses?
Yes
No
Was a police report filed?
Yes
No
Was a traffic violation issued?
Yes
No
If yes, to whom?
PATIENT CONDITION
Were you unconscious immediately after the accident?
Yes
No
If yes, for how long?
Please describe how you felt immediately after the accident:
TREATMENT
Did you go to the hospital?
Yes
No
When did you go
Immediately after accident
Next day
2 days or more after the accident
How did you get to the hospital?
Ambulance
Private transportation
Name of hospital
Name of doctor
Diagnosis
Treatment received
X-rays taken
SYMPTOMS/ INJURIES
Have you been able to work since this injury?
Yes
No
How many work days have you missed?
Prior to the injury were you able to work on an equal basis with others your age?
Yes
No
If you have had any of the following symptoms since your injury, please check:
Arm/shoulder pain
Back pain
Back stiffness
Chest pain
Dizziness
Ear buzzing
Ear ringing
Fatigue
Feet/toe numbness
Hand/finger numbness
Headaches
Irritability
Jaw problems
Leg pain
Memory loss
Nausea
Neck pain
Neck stiff
Shortness of breath
Sleep difficulty
Stomach upset
Tension
Vision blurred
Is this condition getting progressively worse?
Yes
No
Unknown
Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)
Least Pain
1
2
3
4
5
6
7
8
9
Severe Pain
10
1 is Least Pain, 10 is Severe Pain
Mark an X on the picture where you continue to have pain, numbness, or tingling.
Type of pain:
Sharp
Aching
Cramps
Dull
Shooting
Stiffness
Throbbing
Burning
Swelling
Numbness
Tingling
How often do you have this pain?
Is it constant or does it come and go?
Does it interfere with your:
Work
Sleep
Daily Routine
Recreation
Activities or movements that are painful to perform:
Sitting
Bending
Standing
Lying Down
Walking
I certify that the above information is correct to the best of my knowledge.
Patient Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: