AUTO ACCIDENT INFORMATION

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              Patient First Name*:        M.I.:        Patient Last Name*:

              Address*: City*: State*: Zip*:

              Home Phone*:   Work Phone*:    Maritial Status:

              Cell Phone*:    Social Security Number*:

              Height*: feet, inches        Weight*: lbs.        Sex*: Female Male

              Date of Birth*:    month 01 02 03 04 05 06 07 08 09 10 11 12   day   year        Email*:

              Date of Accident:    month 01 02 03 04 05 06 07 08 09 10 11 12   day   year ,Time:

              Location of Accident: city: state:

              The other vehicle:
                             there was no other vehicle
                             hit me in the rear
                             ran a red light
                             was turning right
                             was turning left
                             was entering from a side street/driveway Yes No
                             ran across my lane Yes No

               My vehicle was:
                             I was not in a vehicle
                             a motorcycle
                             at a traffic light
                             at a stop sign
                             going straight
                             turning right
                             turning left
                             was entering from a side street/driveway Yes No
                             stopped for traffic ahead Yes No
                             traveling at mph
                             Vehicle Year: Make: Model: manual automatic

               Where in the vehicle were you sitting? driver front passenger backseat driverside backseat passenger side backseat middle three or more rows back pedestrian-no vehicle

               Check the areas where the car was struck:

               Road conditions were: dry damp wet dark clear raining

               Visability was: poor fair good

               The road was made of: concrete asphalt gravel dirt
                              other :

               Headrest position: up middle down not applicable

               Were you wearing your seatbelt or harness? yes no not applicable

               Did your airbag deploy? yes no not applicable

               Head position: At the time of the accident I was looking:
                              straight ahead to the right to the left up down
                              other :

               Brakes: Were the brakes applied at the time of impact? yes no not applicable

               Elbows: Which elbow was on the armrest? right left neither not applicable
                              other :

               Hands: Which hand was on the steering wheel? right left neither both
                              can't remember other :

               Were you aware of the impending collision before it happened? yes no

               Did you tighten your body and brace for the collision? yes no

               Hands: As a result of the impact:
                              grabbed the stering wheel tightly were forced off the wheel or shifter
                              other :

               As a result of the impact, your body was thrown primarily:
                              forward backward right left
                              turned to the right (clockwise) turn to the left (counter clockwise)
                              can't remember other :

               As a result of the impact, your head primarily contacted:
                              my seat's headrest nothing
                              front windshield rearview mirror steering wheel
                              back of the seat ahead of me inside interior window or door
                              another person's body other :

               As a result of your impact, your shoulders were:
                              pressed firmly against the shoulder harness / seatbelt
                              impacted with the inside of the door, window or car interior
                              other :

               As a result of the collision what other parts of your body struck the inside of the vehicle?
                              ankles: Yes No , elbows: Yes No , face: Yes No
                              chest: Yes No , thighs: Yes No , forearms : Yes No
                              other : other :

               Did another car hit you? yes no

               Did your vehicle strike or impact with a second object after the first impact? yes no

              Did your vehicle strike a car truck road/median building not applicable
                              other :

              Were you wearing your glasses at the time of the accident?
                             yes, but they fell off
                             yes, and they did not fall off
                             I was not wearing my glases
                             I do not wear glasses

               Did you lose consciousness as a result of the accident? yes no
                              If so, for how long?

               Damage to my vehicle was mild moderate severe not applicable

               Damage to other vehicle was mild moderate severe not applicable

               Estimated cost to repair your car: $

               After the accident the car was totalled driveable not driveable not applicable

               At the time of the accident, how many people were with you?

               Names of the occupants:
                              1.
                              2.
                              3.
                              4.
                              5.
                              6.
                              7.

               Were the other occupants injured? yes no
                              If yes, please explain:

              Were the police called to the scene? yes no

              Was a police report written? yes no

              Did you receive a ticket? yes no

              Was the other driver ticketed? yes no

              As a result of the accident I felt my symptoms:
                             immediately within one hour within 6 hours during the night
                             next morning next day other :

              As a result of the accident I felt:
                             headaches upper back pain chest pain/soreness wrist/elbow pain/soreness
                             neck pain low back pain stomach pain/soreness knee/ankle pain/soreness
                             shoulder pain numb, tingling or buring arms numb, tingling or buring legs
                             loss of bowel / bladder control
                            list all other symptoms:

              Please list locaiton of any cuts or bruises if applicable:
             

              Did you go to the hospital? yes no
                            If no, where did you go? home work Doctor
                            If yes, when? immediately next day later in the same day other
                            If yes, how did you get there? ambulance private transportation
                                           drove self someone else drove
              Name of the hospital:
              Were you admitted to the hospital? yes no
                            If yes, for how long?
              Hospital treatment:
              exams Yes No , xrays Yes No , ct scan Yes No , mri Yes No , labwork Yes No , other:

              What follow-up recommendations were made?
               see your own doctor Yes No , see orthopedist / neurologist Yes No
               physical therapist Yes No , braces / collars Yes No , released Yes No , other:

              Please list any medications you were prescibed:
                            
                            
                            
                            

              Please list any doctors you have seen since the accident:

              Are you working now? yes no

              Were you employed at the time of this accident? yes no

              Type of work you do, title:

              Are you currently working with restrictions? yes no

              Has the doctor placed you on total disability partial disability none

              Please list work restirctions:
              

              Please list any special tests ordered by the hospital or doctor :
              

              Since the accident do you feel: worse no improvement better other :

               % of improvement since the accident: 0% better 10% better 20% better 30% better 40% better 50% better 60% better 70% better 80% better 90% better 100% better

               Pain scale 1-10 with 10 being the worse: 0-no pain 1 2 3 4 5 6 7 8 9 10-unbearable

               Please inlcude any additional notes below:
              

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