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Accident Form
Your Name
Date of Accident
Time of Accident
DESCRIPTION OF ACCIDENT / INJURY:
Type of Accident/Injury:
Automobile Accident
Slip/Fall Accident
Workman Compensation Accident/Injury
Pedestrian Accident
Other Accident/Injury
What was the cause of your accident/injury?
Describe in your own words what happened:
Were you:
Driver
Passenger(front)
Passenger(back)
Pedestrian
Were you wearing seatbelts?
Yes
No
Your approximate speed
Other vehicle approximate speed
Did you strike your?
Head
against the
dashboard
windshield
steering wheel
right door
left door
seat frame
unknown object
Shoulder
Side
None
Left
Right
Both
against the
dashboard
windshield
steering wheel
right door
left door
seat frame
unknown object
Arm
Side
None
Left
Right
Both
against the
dashboard
windshield
steering wheel
right door
left door
seat frame
unknown object
Elbow
Side
None
Left
Right
Both
against the
dashboard
windshield
steering wheel
right door
left door
seat frame
unknown object
Wrist
Side
None
Left
Right
Both
against the
dashboard
windshield
steering wheel
right door
left door
seat frame
unknown object
Hip
Side
None
Left
Right
Both
against the
dashboard
windshield
steering wheel
right door
left door
seat frame
unknown object
Knee
Side
None
Left
Right
Both
against the
dashboard
windshield
steering wheel
right door
left door
seat frame
unknown object
Ankle
Side
None
Left
Right
Both
against the
dashboard
windshield
steering wheel
right door
left door
seat frame
unknown object
IMMEDIATELY AFTER ACCIDENT / INJURY:
Did you lose consciousness?
Yes
No
Don't Know
How did you feel?
Confused
Dazed
Dizzy
Nervous
Weak
Where did you immediately develop pain?
Head
Neck
Upper/Mid Back
Lower Back
Pelvis
Chest
Abdomen
Side
None
Left
Right
Both
Shoulder(s)
Side
None
Left
Right
Both
Arm(s)
Side
None
Left
Right
Both
Elbows(s)
Side
None
Left
Right
Both
Forearms(s)
Side
None
Left
Right
Both
Wrist(s)
Side
None
Left
Right
Both
Hand(s)
Side
None
Left
Right
Both
Foot/Feet
Side
None
Left
Right
Both
Buttock(s)
Side
None
Left
Right
Both
Hip(s)
Side
None
Left
Right
Both
Thighs(s)
Side
None
Left
Right
Both
Knees(s)
Side
None
Left
Right
Both
Leg(s)
Side
None
Left
Right
Both
Ankle(s)
Other
If there were lacerations (cuts) where are/were located
If there were any bruises where are/were they located
Describe any other significant injury?
Did you receive care?
Yes
No
What type of emergency care did you receive?
Where did you go?
Hospital
Home
School
Work
Other
By whom were you driven?
Self
Ambulance
Friend
Family
Other
When did you go to the hospital?
Immediately
Later that day
Next Day
Days later
Hospital Name
Were you admitted?
Yes
No
Date discharged?
If x-rays were taken of what body parts?
What treatment was administered at the hospital?
Oral Meds
Sutures
Injection
Bandages
Ice Packs
Hot Packs
Collar
Cast
Brace
Surgery
Topical Antiseptics
Other
Instructions given when discharged from hospital: Were you told to see?
General Practitioner
Physical Therapist
General Surgeon
Chiropractor
Orthopedist
Neurologist
Internist
Plastic Surgeon
Were mediations prescribed?
Pain
Anti Inflammatory
Antibiotics
Other
How much after did additional symptoms develop?
Immediately
Hours
That Evening
Next Morning
Days
Weeks
Month
Other time frame:
What additional symptoms developed?
Pain
Stiffness
Numbness
Tingling
What body parts did this happen in?
Since your accident/injury have you suffered from?
Blurred Vision
Chest Pain
Nausea
Double Vision
Difficulty Breathing
Vomiting
Reduced Vision
Palpitations
Frequent Urination
Diarrhea
Impaired Hearing
Ringing in Ears
Painful Urination
Constipation
Have you experienced any of the following?
Anxiety
Convulsions
Restlessness
Depression
Dizziness
Insomnia
Mood Swings
Headaches
Light Sensitivity
Nervousness
Fainting
Reduced Appetite
Poor Memory
Weakness
Loss of Balance
Tension
Fatigue
Other
Have you missed work due to this accident/injury?
Yes
No
Did you self treat your problems?
Ice
Heat
Bed rest
Over the counter meds
Have you contacted an insurance adjuster or representative regarding this claim?
Yes
No
Company
State in which policy is in effect
Adjuster
Claim #
Claims Address
Have you engaged services of an attorney?
Yes
No
Attorney
Phone
Address
Have you filed an accident/injury report?
Yes
No
Have you filed for insurance benefits?
Yes
No
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