"Auto Accident Injury Information Form"

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Auto Accident Injury Information
Name:____________________________
Today’s Date:_____________
Date of Accident:___/___/_____
Name of Attorney (If Represented):_____________________________
Please describe how the accident occurred (give details):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
What was your position in the vehicle?
( ) The driver
( ) The rear passenger ( ) The front passenger
( ) A pedestrian
( ) Other: ____________
What type of vehicle were you driving?
( ) Compact car ( ) Full size car
( ) Full size truck
( ) Full size van
( ) Mid size car
( ) Compact truck ( ) Mini van ( ) Compact
( ) sport utility
vehicle ( ) Full size sport utility vehicle ( ) Motorhome
( ) Motorcycle ( ) Bicycle
( ) Other: ____________
What speed were you traveling at the time of the accident?
( ) Stopped at a stop light ( ) At a complete stop ( ) Slowing down at an intersection ( ) Moving slowly ( ) Traveling at approximately ___ mph
( ) Merging into traffic ( ) Traveling faster than 65 mph ( ) Other: _____________________
Who hit whom?
( ) Was struck by another vehicle
( ) Struck a stationary object ( ) Struck another vehicle
( ) Other: _____________
What was your vehicle's point of impact?
( ) On the front ( ) On the left front ( ) On the rear ( ) On the left rear ( ) On the right front ( ) On the middle front ( ) On the right rear ( ) On the middle rear
( ) On the right side ( ) On the rear right side ( ) On the left side ( ) On the front right side ( ) On the middle right side ( ) On the front left side
( ) On the rear left side ( ) On the middle left side ( ) Other: __________
What speed was the other vehicle traveling?
( ) Stopped at a stop light ( ) At a complete stop ( ) Slowing down for an intersection ( ) Moving slowly ( ) Merging into traffic ( ) Traveling faster than 65 mph
( ) Traveling at approximately ___ mph ( ) Other: ______________________
What was the other vehicle's point of impact?
( ) On the front ( ) On the left front ( ) On the rear ( ) On the right front
( ) On the middle front
( ) On the right rear ( ) On the left rear ( ) On the right
side ( ) On the rear right side ( ) On the middle rear
( ) On the front right side ( ) On the middle right side ( ) On the left side ( ) On the rear left side
( ) On the front left side ( ) On the middle left side ( ) Other: ______________
Were you wearing seat restraints?
( ) Was wearing a full lap and shoulder restraint
( ) Was wearing a shoulder restraint ( ) Was wearing a lap restraint ( ) Was not wearing any seat restraints
( ) Other: ______________________
What position were your vehicle head rests in?
( ) Did have a head rest which was adjusted in the lowest position ( ) Did have a head rest which was adjusted in the middle position
( ) Did have a head rest which was adjusted in the highest position ( ) Was not equipped with a head rest
( ) Other: _____________________
Did your air bag deploy?
( ) Air bags were deployed
( ) Air bags were not deployed
( ) Other:____________
Were you prepared for the impact?
( ) Was completely surprised by the accident ( ) Saw the collision coming and braced appropriately ( ) Saw the collision coming
( ) Other: _____________________
What position was your body in just prior to impact?
( ) A straight position ( ) A position rotated to the left ( ) A tilted forward position ( ) A position rotated to the right ( ) A position that cannot be remembered
( ) Other: _________________
Auto Accident Injury Information
Name:____________________________
Today’s Date:_____________
Date of Accident:___/___/_____
Name of Attorney (If Represented):_____________________________
Please describe how the accident occurred (give details):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
What was your position in the vehicle?
( ) The driver
( ) The rear passenger ( ) The front passenger
( ) A pedestrian
( ) Other: ____________
What type of vehicle were you driving?
( ) Compact car ( ) Full size car
( ) Full size truck
( ) Full size van
( ) Mid size car
( ) Compact truck ( ) Mini van ( ) Compact
( ) sport utility
vehicle ( ) Full size sport utility vehicle ( ) Motorhome
( ) Motorcycle ( ) Bicycle
( ) Other: ____________
What speed were you traveling at the time of the accident?
( ) Stopped at a stop light ( ) At a complete stop ( ) Slowing down at an intersection ( ) Moving slowly ( ) Traveling at approximately ___ mph
( ) Merging into traffic ( ) Traveling faster than 65 mph ( ) Other: _____________________
Who hit whom?
( ) Was struck by another vehicle
( ) Struck a stationary object ( ) Struck another vehicle
( ) Other: _____________
What was your vehicle's point of impact?
( ) On the front ( ) On the left front ( ) On the rear ( ) On the left rear ( ) On the right front ( ) On the middle front ( ) On the right rear ( ) On the middle rear
( ) On the right side ( ) On the rear right side ( ) On the left side ( ) On the front right side ( ) On the middle right side ( ) On the front left side
( ) On the rear left side ( ) On the middle left side ( ) Other: __________
What speed was the other vehicle traveling?
( ) Stopped at a stop light ( ) At a complete stop ( ) Slowing down for an intersection ( ) Moving slowly ( ) Merging into traffic ( ) Traveling faster than 65 mph
( ) Traveling at approximately ___ mph ( ) Other: ______________________
What was the other vehicle's point of impact?
( ) On the front ( ) On the left front ( ) On the rear ( ) On the right front
( ) On the middle front
( ) On the right rear ( ) On the left rear ( ) On the right
side ( ) On the rear right side ( ) On the middle rear
( ) On the front right side ( ) On the middle right side ( ) On the left side ( ) On the rear left side
( ) On the front left side ( ) On the middle left side ( ) Other: ______________
Were you wearing seat restraints?
( ) Was wearing a full lap and shoulder restraint
( ) Was wearing a shoulder restraint ( ) Was wearing a lap restraint ( ) Was not wearing any seat restraints
( ) Other: ______________________
What position were your vehicle head rests in?
( ) Did have a head rest which was adjusted in the lowest position ( ) Did have a head rest which was adjusted in the middle position
( ) Did have a head rest which was adjusted in the highest position ( ) Was not equipped with a head rest
( ) Other: _____________________
Did your air bag deploy?
( ) Air bags were deployed
( ) Air bags were not deployed
( ) Other:____________
Were you prepared for the impact?
( ) Was completely surprised by the accident ( ) Saw the collision coming and braced appropriately ( ) Saw the collision coming
( ) Other: _____________________
What position was your body in just prior to impact?
( ) A straight position ( ) A position rotated to the left ( ) A tilted forward position ( ) A position rotated to the right ( ) A position that cannot be remembered
( ) Other: _________________
What 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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