Shiloh Chiropractic Motor Vehicle Accident Questionnaire Page 2
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4SHILOH CHIROPRACTIC MOTOR VEHICLE ACCIDENT QUESTIONNAIRE
PAGE 1 of 3
ACCIDENT DETAILS
Please fill this form out as completely as you can! It’ll save time for you in the long run! This is a worksheet that you can
fill out that will help Dr. Rice compile your narrative for insurance purposes as well as helps him to understand what is
going on so you can get better faster!
Name: ________________________________________
Today: _____/_____/20_____
AM
Date of Accident: _____/_____/20_____
Time of Accident: ____:____
/
PM
How many cars were involved? _________
Were you the “At fault” party? ________________________________
Were you:
Driver
Passenger
City/State of Accident: _______________________________________
I was driving (direction):____________ -bound on (road):__________________________________________________
Were there any passengers in your car? _____________ Who? _____________________________________________
Were you all wearing your seatbelts? __________________________________________________________________
Was there any airbag deployment? ____________________________________________________________________
Was anyone from any vehicle taken to the hospital? __________ If Yes, Explain: _______________________________
__________________________________________________________________________________________________
Was anyone given a ticket? _______ Who? ______________ For What? _______________________________________
Was there a Police Report? ___________
County or City? ____________________________________________
Please bring in copy or tell us how to get one. If there is a cost associated with getting this, we will pay for this up to $50.
Draw in your accident here (label cars, streets and directions!)
VEHICLE DESCRIPTION
If you are unsure how to do this – LEAVE IT BLANK!
(example) Unit 2: `99 4-dor Grand Am
(example) Unit 3: Late 90’s large SUV
You are Unit 1.
The other person is Unit 2. If there
were other vehicles, label them Unit 3 and so on.
Unit 1:
Unit 2:
Unit 3:
Unit 4:
mva_questionnaire.doc
rev 07/10
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