Your Name

Date of Accident

Time of Accident

Description 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

Head dashboard windshield steering wheel right door left door seat frame unknown object Shoulder dashboard windshield steering wheel right door left door seat frame unknown object Arm dashboard windshield steering wheel right door left door seat frame unknown object Elbow dashboard windshield steering wheel right door left door seat frame unknown object Wrist dashboard windshield steering wheel right door left door seat frame unknown object Hip dashboard windshield steering wheel right door left door seat frame unknown object Knee dashboard windshield steering wheel right door left door seat frame unknown object Ankle dashboard windshield steering wheel right door left door seat frame unknown object

Did you lose consciousness? Yes No Don't Know

Confused Dazed Dizzy Nervous Weak Head Neck Upper/Mid Back Lower Back Pelvis Chest Abdomen

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 di 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

If x-rays were taken of what body parts?

Date discharged?

Oral Meds Sutures Injection Bandages Ice Packs Hot Packs Collar Cast Brace Surgery Topical Antiseptics Other General Practitioner Physical Therapist General Surgeon Chiropractor Orthopedist Neurologist Internist Plastic Surgeon Pain Anti Inflammatory Antibiotics Other

How much after did additional symptoms develop? Immediately Hours That Evening Next Morning Days Weeks Month

Other

Pain Stiffness Numbness Tingling

What body parts did this happen in?

Blurred Vision Chest Pain Nausea Double Vision Difficulty Breathing Vomiting Reduced Vision Palpitations Frequent Urination Diarrhea Impaired Hearing Ringing in Ears Painful Urination Constipation 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

Ice Heat Bed rest Over the counter meds

Have you contacted an insurance adjuster or representative regarding this claim? Yes No

Company

Statein which policy is in effect

Adjuster

Claim #

Claims Address

Have you engaged services of an attorney? Yes No

Attorney

Address

Phone

Have you filed an accident/injury report? Yes No

Have you filed for insurance benefits? Yes No