Auto Collision and/or Accident Questionnaire
Name
First Name
Last Name
Date of Accident
Use the spaces below to fully describe your accident injury or onset, slip and fall. etc.
Description of auto collision and/or accident: Enter a full description of the auto collision and/or accident.
Your condition during and immediately after auto collision and/or accident: Enter details of your condition during and immediately after your injury.
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Automobile Collision Description
Date of the Auto Collision
Vehicle Type
Please Select
Compact Car
Full Size Car
Small Pickup Truck
Large Pick up Truck
Small SUV
Mid-size SUV
Large SUV
Motorcycle
Bicycle
Van
Eighteen Wheeler Truck
School Bus
City Bus
Box Truck
Mail Truck
Ambulance
Other
Your position in the vehicle
Please Select
Driver
Front passenger
Left rear passenger
Middle rear passenger
Right rear passenger
Passenger on bus
Other
What was your vehicle doing at time of auto collision
Please Select
Stopped at light
Making a right turn
Making a left turn
Accelerating
Attempting to stop
Slowing down
Changing lanes
Driving in parking lot
Moving in reverse
Parked
Sliding/spinning out of control
Slowing down
Yielding
Time of auto collision
Your vehicle's speed
Other vehicle's speed
Damage to your vehicle
Mild
Moderate
Total
Visibility at the time of accident
Poor
Fair
Good
Who hit who or what?
You hit other vehicle
Other vehicle hit you
Road Condition
Please Select
Icy
Wet
Sandy
Dark
Clean and dry
Snow covered
Impact Area
Please Select
Front bumper
Rear bumper
Driver's Side
Passenger's Side
Front driver';s side corner
Rear driver's side corner
Front passenger side corner
Rear passenger side corner
Rear trailer
Did you see the accident coming?
Yes
No
Were you braced for the impact?
Yes
No
Did you have your seat belt on?
Yes
No
Head Rest Position
Please Select
High
Middle
Low
Unknown
Did Air Bags Deploy?
Yes
No
Lighting Conditions
Please Select
Night
Dawn
Dusk
Full Daylight
Visibility
Please Select
Excellent
Fair
Good
Poor
Compromised by:
Please Select
Brightness/Sun
Darkness
Fog
Rain
Snow
Traffic
Opposing vehicle type
Please Select
Compact Car
Full Size Car
Small Pickup Truck
Large Pickup Truck
Small SUV
Mid Size SUV
Large SUV
Motorcycle
Van
18 Wheeler Truck
School Bus
City Bus
Bicycle
Box Truck
Mail Truck
Pickup Truck pulling a Trailer
Police Vehicle
Dump Truck
Bucket Truck
Ambulance
Tow Truck
Garbage Truck
Your Vehicle Type
Please Select
Compact Car
Full Size Car
Small Pickup Truck
Large Pickup Truck
Small SUV
Mid-size SUV
Large SUV
Mid SUV
Bicycle
Motorcycle
Van
18 Wheeler Truck
Other
Admitted to Hospital?
Yes
No
Admission Time
Please Select
At Time of the Accident
At a Later Time
Transportation to Hospital
Please Select
Ambulance
Life Flight
Police Car
Private Transportation
Other
Bracing Status
Please Select
I was able to brace for impact
I was aware that the accident was impending but was unable to brace
I was not aware the accident was impending
Injury Locations
Neck
Upper Back
Mid Back
Lower Back
Back of Head
Forehead
Chest
Rib Cage
Abdomen
Face
Nose
Side of Head
Side of Face
Right Shoulder
Left Shoulder
Right Arm
Left Arm
Right Elbow
Left Elbow
Right Forearm
Left Forearm
Right Wrist/ Hand/ Finger
Left Wrist/ Hand/ Finger
Right Hip
Left Hip
Right Thigh
Left Thigh
Right Knee
Left Knee
Right Leg
Left Leg
Right Ankle/ Foot/ Toe
Left Ankle/ Foot/ Toe
Other
Feeling after the accident
Please Select
Angry
Disoriented
Dizzy
Nausea
Nervous
Scared
Upset
Unconscious
Weak
Pain
Other
If Admitted, what tests and/or treatments did you receive?
If treated by another medical provider, tell what type of provider, the date received treatment, and tests or treatments received.
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Risk Factor Accidental Questionnaire
Are you female with a small build frame?
Yes
No
Did your pain start immediately after the accident occurred?
yes
no
Is this your first time ever experiencing neck and/or back pain?
yes
no
Are you having any difficulty with making decisions since the accident?
yes
no
Did you suffer with more than one injured area as a result of the accident?
yes
no
Were you wearing a seat belt and/or shoulder harness during the accident?
yes
no
Do you have a history of neck pain and/or headaches?
yes
no
Do you have osteoarthritis of your neck and/ or back?
yes
no
Have you been told that you have a loss of any curvature in your neck?
yes
no
Are you considered a middle age or older person?
yes
no
Were you a front seat passenger or driver in the vehicle of the accident?
yes
no
Do you have a metabolic disorder like diabetes?
yes
no
Do you have congenital anomalies of your spine?
yes
no
Do you have a history of herniated disc of your spine?
yes
no
Do you have rheumatoid arthritis, or other arthritic conditions affecting your spine
yes
no
Do you have ankylosing spondylitis of your spine?
yes
no
Do you have scoliosis or curvature of the spine?
yes
no
Do you have a medical history of spinal surgery?
yes
no
Do you have a medical history of prior vertebral (spinal) fractures?
yes
no
Do you suffer from osteoporosis?
yes
no
Do you suffer from Paget's disease or other disease of the bone?
yes
no
Are you a paraplegic or quadriplegic?
yes
no
Do you have a medical history of prior spinal injury?
yes
no
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