• Auto Collision / Personal Injury Intake Form

  •  - -
  •  - -

  • Your Auto Insurance Information

  • Other Party‘s Auto Insurance Information (If Applicable)

  • Collision Information

  •  - -

  • Your Vehicle:

  • Other Vehicle:

  • Witnesses

  • For this Car Collision

  • Self-Care

  • Symptomatology: (Pain / Complaints) from this collision, even if only felt momentarily

  • Miscellaneous

  • Your Overall Body Picture

  • Use symbols below to accurately mark the areas in which you feel

      Sharp: SSSS  Tingling: TTTT  Burning: BBBB  Cramping: CCCC
     Numbness: NNNN  Dull: DDDD   Achy: AAAA  Pin / Needles: PPPP

  • Please prioritize each condition worst condition to least

  • (1st) First Body Part

  • (2nd) Second Body Part

  • (3rd) Third Body Part

  •

  • (4th) Fourth Body Part

  • (5th) Fifth Body Part

  •

  • (6th) Sixth Body Part

  •

  • Effects of your Injuries / Symptoms

  • How do the following positions or motions affect your pain?

  • If increased, duration limited to #?

  • If increased, duration limited to #? .

  • If increased, duration limited to #? .

  • If increased, duration limited to #? .

  • If increased, duration limited to #? .

  • If increased, interrupted: Current # of hours uninterrupted Prior # of hours uninterrupted.

  • Employment History / Change

  • Prior Medical History You Have Been Treated For

    (Before / Outside This Car Crash)

  • Personal Medical History & Review of Systems

    Please indicate with check mark any medical problems that you currently have or have had in the past.

  • Family Medical History

    (Mom, Dad, Brother, Sisters, Aunts, Uncles, Grandparents)

  • Social Habits:

  • Alcohol:     OR   Drinks per week 
    Smokes:    OR                        
    Recreational Drugs:                        

  • Exercise Habits:

  • Hobbies:

  • I ATTEST THAT  I have reviewed whole form of this Auto Collision/ Personal Injury Intake form and the information I have provided, is to the best of my Abilities, Truthful/ Factual/ Accurate.

  • Clear
  •  - -
  • Should be Empty: