PERSONAL INJURY - AUTO/CYCLE ACCIDENT HISTORY
Is your injury auto-related?
Yes
No
What type of accident caused your injury?
Two or more automobiles
Injured by a vehicle as a pedestrian
Motorcycle/Bicycle and no Vehicle
An automobile and a Motorcycle/Bicycle
Other
When did the accident occur?
-
Month
-
Day
Year
Date
Where in the vehicle were you at the time of the accident?
What were you doing at the time of the accident?
In what direction were you looking at the time of impact?
What is the size/type of your vehicle?
Were you wearing a seatbelt?
Yes
No
What type of protection did you have?
Did the airbag deploy?
Yes
No
Did you come in contact with anything at the time of the collision?
Yes
No
What was the position of the headrest (in relation to your head)?
Did you receive an injury to the head?
Yes
No
Did you lose consciousness?
Yes
No
Did police arrive at the scene?
Yes
No
Was an accident report taken?
Yes
No
Which part of your vehicle was impacted? Choose all that apply.
Front right
Front left
Front head on
Rear end - center
Rear right
Rear left
Left side (driver's side)
Right side (passenger's side)
Unknown
What type of protection did you have?
In what direction was your vehicle or cycle moving?
What was the estimated speed of your vehicle or cycle?
What was the extent of the damage to your vehicle?
What was the extent of the damage to the other vehicle or cycle?
In what direction was the other vehicle or cycle moving?
What was the estimated speed of the other vehicle or cycle?
Was your vehicle or cycle towed from the scene?
Yes
No
Did Emergency Medical Services arrive at the scene?
Yes
No
How did you leave the scene of the accident?
Where was discomfort felt immediately following the accident?
Describe your discomfort after the accident.
What treatment, if any, have you received since the accident?
Are there any additional symptoms which have appeared since the accident occurred?
Yes
No
How have your symptoms changed since the accident?
Worsened
Remained the same
Improved
PERSONAL INJURY - NON-AUTO ACCIDENT HISTORY
What type of accident caused your injury?
Work injury (but not auto related)
Slip and fall (away from home)
Home Injury
Sports injury
Other
What is the date of your scheduled appointment?
-
Month
-
Day
Year
Date
When did the accident occur?
-
Month
-
Day
Year
Date
What were you doing at the time of the accident?
In what direction were you looking at the time of impact?
Did you receive an injury to the head?
Yes
No
Did you lose consciousness?
Yes
No
Did police arrive at the scene?
Yes
No
Was an accident report taken?
Yes
No
Did Emergency Medical Services arrive at the scene?
Yes
No
How did you leave the scene of the accident?
Where was discomfort felt immediately following the accident?
Describe your discomfort after the accident.
What treatment, if any, have you received since the accident?
Are there any additional symptoms which have appeared since the accident occurred?
Yes
No
How have your symptoms changed since the accident?
Worsened
Remained the same
Improved
Submit
Should be Empty: