Auto Accident Injury Information Form Page 2
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2What happened to your body the moment of impact?
( ) Body was tensed for impact ( ) Body violently torqued and twisted ( ) Body whipped violently forward and backward
( ) Body was thrown over the seat
( ) Body was thrown from the vehicle
( ) Body was thrown violently from side to side ( ) Body was pinned in the vehicle
( ) Body was badly cut and bruised
( )
Other: __________________
What was your mental/emotional state immediately following the accident?
( ) Was not rendered unconscious by the impact of the accident ( ) Was rendered unconscious by the impact of the accident
( ) Was not rendered unconscious but was shaken and disoriented ( ) Was not rendered unconscious but was shaken up
( ) Was not rendered unconscious but was disoriented ( ) Other: __________________
Did you receive medical attention at the scene of the accident?
( ) Did receive medical attention ( ) Did not receive medical attention ( ) Other: __________________
Where did you go immediately following the accident?
( ) Was taken to the hospital by ambulance ( ) Was driven to hospital ( ) Was taken to a personal physician ( ) Was taken home ( ) Was taken to this office
( ) Resumed activities ( ) Other: ___________________
If Hospitalized, how long? _________________
Hospital Name:______________________________________
Did your symptoms develop?
( ) Immediately ( ) Hours later ( ) The next day ( ) Over the first few days ( ) During the first week ( ) Over the next few weeks
If you were treated by another doctor or therapist, answer the following questions:
Name of doctor or facility:______________________________________
Date of Exam:___/___/_____
Treatment received: ( ) X-rays ( ) CT Scan
( ) MRI What body part(s)?____________________________________
Was Medication prescribed? ( )YES
( )NO
Date of last appointment: ___/___/_____
Name of doctor or facility:______________________________________
Date of Exam:___/___/_____
Treatment received: ( ) X-rays ( ) CT Scan
( ) MRI What body part(s)?____________________________________
Was Medication prescribed? ( )YES
( )NO
Date of last appointment: ___/___/_____
List each of your body parts that struck the following vehicle parts during the accident (Answer if applicable)
Dashboard:
_____________________________________________________
Windshield:
_____________________________________________________
Steering Wheel:
_____________________________________________________
Right Door:
_____________________________________________________
Left Door:
_____________________________________________________
Seat Frame:
_____________________________________________________
Unknown Object: ____________________
_____________________________________________________
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