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449 EAST FERRY STREET BUFFALO, NY 14208
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East Buffalo Chiropractic | Chiropractor Buffalo NY | Auto Accident | Car Accident | Doctor | Buffalo | NY
Auto – Car Accident Doctor Buffalo, NY | Chiropractor Buffalo NY
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Home
About
Our Team
Conditions
Services
Forms
New Patient Info
Auto Accident Form
Testimonials
Education
Contact Us
Contact Us
My Account
Site Login
Auto Accident Questionnaire
If you are human, leave this field blank.
Date of Accident
*
Time of Accident
*
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Please describe how the accident happened
*
What was your position in the vehicle
*
Driver
Passenger Front
Passenger Left Rear
Passenger Right Rear
Passenger Middle Rear
Were your hands on the steering wheel?
*
Yes
No
Which hand(s)
*
Both Hands
Right Hand
Left Hand
Did the airbags deploy
*
Yes
No
Did you strike another vehicle?
*
Yes
No
Angle of Impact
*
Front
Back
Left
Right
Other
Other
Was there a second collision?
*
Yes
No
Did another vehicle strike you?
*
Yes
No
Angle of Impact
*
Front
Back
Left
Right
Other
Other
In relation to the back of your head, was your headrest set?
*
Low
Middle
High
Were you surprised by the impact?
*
Yes
No
Year of Vehicle
*
Make of Vehicle
*
Model of Vehicle
*
What was your approximate speed when the accident occurred
*
Approximate Year of other vehicle involved
*
Approximate Make of other vehicle involved
*
What was the approximate speed of other vehicle
*
Were you wearing a seatbelt
*
Yes
No
What type
*
Lap Belt
Shoulder Belt
Both
Did you feel pain immediately following the accident?
*
Yes
No
Were you rendered unconscious as a result of the accident
*
Yes
No
Did you strike anything in the vehicle at the time of the impact
*
Yes
No
What part of your body
*
What did it strike?
Steering Wheel
Dashboard
Left Side Door
Left Window
Windshield
Roof
Right Side Door
Right Window
Other
Other
Did your seat break or bend?
*
Yes
No
Immediately following the accident, how did you feel
*
Dizzy
Dazed
Weak
Upset
Disoriented
Nervous
Nauseous
Other
Other
Check all that apply please
Were police notified?
*
Yes
No
Were traffic citations issued?
*
Yes
No
To Whom?
*
Did you go to the hospital?
*
Yes
No
When?
*
How did you get there?
*
Ambulance
Police Car
Private Transportation
Were you admitted?
*
Yes
No
How long were you there? (Days)
*
Name of Hospital
*
Attended by Dr.
*
Full name please
Treatment Given
*
X-rays
Pain Medication
Stitches
Muscle Relaxants
Bandaged
Cervical Collar
Physical Therapy
Instructed Regarding Concussion
Instructed Regarding Sprains & Strains
Instructed to Call an Orthopedist
Instructed to Call a Private Physician
Referred to This Office
None
Other
Other
Have you seen any other doctor for this injury?
*
Yes
No
Do you have difficulty in excessive
*
Standing
Walking
Riding
Bending
Twisting
Do you have difficulty in excessive lifting
*
Light
Moderate
Heavy
Repetitive
Any other symptoms other than the last 2 questions?
*
Yes
No
Please tell us about them
*
Signature
*
Clear
Submit
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