AUTOMOBILE ACCIDENT HISTORY

Name: ___________________________ Age: ______ Date of Birth: _____________ □ M □ F

Address: ___________________________________________________________________

City: ________________________________________State: _________ Zip Code: _________

SS#:____________________________ Driver’s License #:_____________________________

Insurance Company: ________________________Name of Agent:_______________________

Address of Insurance Company:___________________________________________________

Have you retained an attorney?  □ Yes  □ No   

Name and Address of Attorney:

_____________________________________________________________________________

GENERAL SYMPTOMS:

Did you hit any part of your body during the collision, for example:

head on dash, chest on steering wheel? □Yes □ No

If yes, which part and how? ______________________________________________________

______________________________________________________________________________

Where were you taken after the accident?___________________________________________

Were you hospitalized?  □ Yes  □ No  If yes, for how long?______________________________

Did you receive care from any other health care specialist?  □ Yes  □ No      

If yes, what is the specialist’s name? _______________________________________________

What type of care were you given and for how long?_________________________________________

Where did you feel the pain?_______________________________________________________

What area your current symptoms?_________________________________________________

Have you ever been injured in a similar manner?   □ Yes    □ No   

If yes, how and when?___________________________________________________________

ACCIDENT HISTORY:

Date of Accident:________________ Time of Accident:__________   □  A.M.     □  P.M.

State how accident happened in your own words: ____________________________________________

______________________________________________________________________________

______________________________________________________________________________

What type of vehicle were you in?  Make: ___________________ Year: _________________________

Were you driving? □ Yes □ No  Was it your care? □ Yes □ No  If not, whose?_____________________

Passenger?    □ Front   □ Back   □ Right Side   □ Left Side         Were you rotated in seat?  □ Yes  □ No

Were you reclined?    □ Yes   □ No   Other:_________________________________________________

Other people in car?   □ Yes   □ No    Names and Addresses: ____________________________________

_____________________________________________________________________________

Were they injured?  □ Yes  □ No     If yes, explain: _____________________________________________________________________________

_____________________________________________________________________________

Seat belts on?  □ Yes □  No     Shoulder harness on?  □ Yes  □ No      Position of Headrest?___________

Was it?   □ Daylight   □ Night   □ Dusk   □ Dawn     What were the weather conditions?______________

Were you tired?   □ Yes   □ No   Were you awake?   □ Yes  □ No   

How long had you been in the car?_________________________________________________________

Where were you prior to the accident? ___________________________________________

What were the traffic conditions? ___________________ What was the posted speed limit? __________

How fast were you going? _________________  

Type of road:   □ 2 Lane   □ 3 Lane   □ 4 Lane  □ Gravel   □ Tar

Did it happen at a/an:       □ Stop Sign        □ Traffic Light        □ Intersection        □ Highway

Was your car hit?    □ Front   □  Back    □ Left Side    □ Right Side   

What damage was done to you car?

Inside: ______________________________________________________________________

Outside: _____________________________________________________________________

Other: _______________________________________________________________________

If you struck another car, did you strike it?   □ Front   □ Back   □ Side  

What was the damage to the other car?

Inside: _______________________________________________________________________

Outside: _____________________________________________________________________________

In what condition was the vehicle prior to the accident? _____________________________________________________

Do you have pictures of the involved automobile?  □ Yes   □ No  

What type of vehicle was involved in the accident?     □ Car   □ Truck   □ Motorcycle  

□ Other: _________________________ Size and Type: _______________________

Was the accident report made?  □ Yes □  No  

Police of: City:_______________ County: ______________ State:_______

Who was ticketed?  ______________________ For what? _____________________________________

Did your vehicle strike anything?  □ Yes  □ No 

If yes,  □ Another car  □ Sign  □ Tree   □ Bridge   □ Hedge  □ An Embankment  

□ Other: ___________________________ Size and Type: __________________________

Were you completely conscious after the impact?       □ Yes       □ No

Do you remember the impact?        □ Yes          □ No             

Did your vehicle go off the road?    □ Yes      □ No  

 If so,    □ Into a Ditch?     □ An Embankment?     How Deep? ______________

Does it bother you to ride in a car now?   □ Yes    □ No    If so, as a    □ Driver   □ Passenger

State any strange events that happened during or immediately after the accident? __________________________________________________________________________

Have you had any time loss from work?   □ Yes    □ No   If yes, from ________to_________

Have you had to have any outside help?   □ Yes     □ No    What type? __________________

PLEASE DRAW THE ACCIDENT

___________________________        ______________          ________________________

Patient Signature                             Date                             Staff Signature