Auto Accident Questionnaire Date of Accident * Time of Accident * 121234567891011 : 0030 AMPM 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 OtherOther Was there a second collision? * Yes No Did another vehicle strike you? * Yes No Angle of Impact * Front Back Left Right OtherOther 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 OtherOther Did your seat break or bend? * Yes No Immediately following the accident, how did you feel * Dizzy Dazed Weak Upset Disoriented Nervous Nauseous OtherOther 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 OtherOther 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 If you are human, leave this field blank. Submit
