Personal Injury Intake Form printable pdf download

Personal Injury Intake Form

It is necessary that if your injuries are due to an automobile accident that we are given the following information within

your first 2 visits or you may become responsible for continued charges. It is necessary to complete the following forms

to best of your ability. Detail is imperative.

Insurance Name: _____________________________ Phone Number:___________________________

Claim Address:__________________________________________________________________

Claim Number:__________________________ Adjuster Name:__________________________

Patient Name:__________________________________________ Date of Accident: _____________________

Time:__________

Where did the accident happen?_______________________________________________________________________

Describe the accident in your own words:

__________________________________________________________________________________________________

What was your position in the car?  Driver  Passenger

If passenger, were you sitting in  Front  Right Rear  Left Rear

Did your vehicle strike other vehicle?  Yes  No

Was your car struck by other vehicle?  Yes  No

Was the impact from:  the front  from the right side  from the left side  from the rear

At the time of impact were you:  looking straight ahead  looking right  looking left

Were both hands on the steering wheel?  Yes  No

Was your foot on the brake?  Yes  No

Were you braced for impact?  Yes  No

Where in the car were you after the accident? __________________________________________________________

Were you wearing seat belts?  Yes  No

Did you strike anything in the vehicle at the time of impact?  Yes  No

Please state part of body:  Chest  Chin  Knee  Shoulder  Hand  Head

Immediately following the accident how did you feel? ____________________________________________________

__________________________________________________________________________________________________

Were you unconscious?  Yes  No

In a daze?  Yes  No

Did you go to the hospital?  Yes  No

How did you get to the hospital?  Ambulance  Private Transportation

Did the ambulance attendants place you in: Neck Collar  Yes  No

Splints  Yes  No Brace  Yes  No

Name of Hospital: _____________________________________________________________________________

Attended by Dr.________________________________________

Were you x-rayed at the hospital?  Yes  No

If Yes, what was the diagnosis? ________________________________________________________________________

Personal Injury Intake Form