Automobile Accident History

AUTOMOBILE ACCIDENT HISTORY
Patient Name*

First Name Last Name
Date of Accident*

MonthDay Year
Date
Email*
example@example.com
Phone Number*

Area Code Phone Number
Your Vehicle Information
Your Vehicle (year, make, model):
Your estimated speed at the moment of the accident:
At the moment of the accident your vehicle was:

StoppedSlowingAccelerating
If stopped, was your foot on the brake?

YesNo
Other Vehicle Information
Other Vehicle (year, make, model):
Estimated speed of the other vehicle at the moment of the impact:
At the moment of impact the other vehicle was:

StoppedSlowingAccelerating
Road Conditions
Road conditions at the time of the accident:

DryDampSnowIce
Visibility conditions at the time of the accident:

DaylightDawnDuskDark
Head restraints, Seat backs
If adjustable, was the position of the headrest altered by the accident?

YesNo
Was the seat back adjustment altered by the accident?

YesNo
Was the seat broken?

YesNo
Seat belts and Air bags
Were you wearing a seatbelt?

YesNoDon't know
What type of seat belt?

Lap seat beltShoulder seat beltShoulder-lap seat belt
Did your air bag deploy?

YesNo
If your air bag deployed, were you struck?

YesNo
Where were you struck by the air bag?
Head and Body position
Which way was your body pointed at the point of impact?

StraightRightLeft
Which way was your head pointed at the point of impact?

StraightRightLeft
Accident Diagram
Accident Diagram
Accident description
Please describe, to the best of your knowledge, what happened during this accident:
During the crash
Position of hands:

One on wheelTwo on wheelN/A
Did you strike any parts of the vehicle?

YesNo
Please describe what parts of the vehicle you struck:
Did you strike any objects after the crash?

YesNo
Please describe what objects you struck:
Were you aware or surprised of the approaching collision?

AwareSurprised
Were you wearing a hat or glasses?

YesNo
Were the hat or glasses still on after the crash?

YesNo
Did you lose consciousness (black out) upon impact?

YesNo
How long did you lose consciousness?
Did you experience a flash of light or explosion in your head?

YesNo
After the crash
Did you become:

ConfusedDisorientedLight HeadedDizzyNauseatedBlurred VisionRing/Buzz in ears
Which of these symptoms are you still experiencing?

ConfusedDisorientedLight HeadedDizzyNauseatedBlurred VisionRing/Buzz in ears
Are you currently suffering from any of the following:

RestlessnessIrritabilityDifficulty concentratingDifficulty with memorySleeplessnessForgetfulnessReduced tolerance to heatReduced tolerance to alcohol
Did the police come to the accident scene?

YesNo
Is there a police report?

YesNo
Hospital
Did you go to the hospital?

YesNo
How did you get to the hospital?
Name and city of hospital:
Name of emergency room doctor:
What parts of body were x-rayed at the hospital?
How long did you stay in the hospital?
What did the hospital do for your injuries?

MedicationsCervical collarIce PackFollow up
List of medications you were given:
Follow up instructions:
Current Complaints
Please list, in detail, all current symptoms / complaints in order of severity.

Symptom #1
Date when symptom first appeared:

MonthDay Year
Date
How often do you experience the symptoms?

Constant 100%Frequent 75%Intermittent 50%Occasional 25%
Describe any recently related accident or fall:
What makes symptom increase?
What gives relief of symptom?
Type of pain:

SharpDullAcheBurnThrobNumbOther
Describe type of pain:
Where does the pain radiate to?
How bad is your pain? (indicate 0 - no pain to 10 - unbearable

0 1 2 3 4 5 6 7 8 9 10
0 is No Pain, 10 is Unbearable Pain
Please mark your areas of pain on the figures below

COLLAPSE STOPPER

Symptom #2
Date when symptom first appeared:

MonthDay Year
Date
How often do you experience the symptoms?

Constant 100%Frequent 75%Intermittent 50%Occasional 25%
Describe any recently related accident or fall:
What makes symptom increase?
What gives relief of symptom?
Type of pain:

SharpDullAchingBurnThrobNumbOther
Describe type of pain:
Where does the pain radiate to?
How bad is your pain? (indicate 0 - no pain to 10 - unbearable

0 1 2 3 4 5 6 7 8 9 10
0 is No Pain, 10 is Unbearable Pain
Please mark your areas of pain on the figures below

COLLAPSE STOPPER

Symptom #3
Date when symptom first appeared:

MonthDay Year
Date
How often do you experience the symptoms?

Constant 100%Frequent 75%Intermittent 50%Occasional 25%
Describe any recently related accident or fall:
What makes symptom increase?
What gives relief of symptom?
Type of pain:

SharpDullAchingBurnThrobNumbOther
Describe type of pain:
Where does the pain radiate to?
How bad is your pain? (indicate 0 - no pain to 10 - unbearable

0 1 2 3 4 5 6 7 8 9 10
0 is No Pain, 10 is Unbearable Pain
Please mark your areas of pain on the figures below

COLLAPSE STOPPER

Symptom #4
Date when symptom first appeared:

MonthDay Year
Date
How often do you experience the symptoms?

Constant 100%Frequent 75%Intermittent 50%Occasional 25%
Describe any recently related accident or fall:
What makes symptom increase?
What gives relief of symptom?
Type of pain:

SharpDullAchingBurnThrobNumbOther
Describe type of pain:
Where does the pain radiate to?
How bad is your pain? (indicate 0 - no pain to 10 - unbearable

0 1 2 3 4 5 6 7 8 9 10
0 is No Pain, 10 is Unbearable Pain
Please mark your areas of pain on the figures below

COLLAPSE STOPPER

Symptom #5
Date when symptom first appeared:

MonthDay Year
Date
How often do you experience the symptoms?

Constant 100%Frequent 75%Intermittent 50%Occasional 25%
Describe any recently related accident or fall:
What makes symptom increase?
What gives relief of symptom?
Type of pain:

SharpDullAchingBurnThrobNumbOther
Describe type of pain:
Where does the pain radiate to?
How bad is your pain? (indicate 0 - no pain to 10 - unbearable

0 1 2 3 4 5 6 7 8 9 10
0 is No Pain, 10 is Unbearable Pain
Please mark your areas of pain on the figures below

COLLAPSE STOPPER
Current Accident
Please list all previous treatments for conditions related to this auto accident including all doctors visits, MRIs, X-rays, etc.
Name of Hospital:
Hospital Phone Number

Area Code Phone Number
Date of Care

MonthDay Year
Date
Tests/Treatments

Treating Doctor #1
Name of Treating Doctor
Address
Phone Number

Area Code Phone Number
Specialty
Date of Care

MonthDay Year
Date
Tests/Treatments

COLLAPSE STOPPER

Treating Doctor #2
Name of Treating Doctor
Address
Phone Number

Area Code Phone Number
Specialty
Date of Care

MonthDay Year
Date
Tests/Treatments

COLLAPSE STOPPER

Treating Doctor #3
Name of Treating Doctor
Address
Phone Number

Area Code Phone Number
Specialty
Date of Care

MonthDay Year
Date
Tests/Treatments

COLLAPSE STOPPER

Treating Doctor #4
Name of Treating Doctor
Address
Phone Number

Area Code Phone Number
Specialty
Date of Care

MonthDay Year
Date
Tests/Treatments

COLLAPSE STOPPER

Treating Doctor #5
Name of Treating Doctor
Address
Phone Number

Area Code Phone Number
Specialty
Date of Care

MonthDay Year
Date
Tests/Treatments

COLLAPSE STOPPER

Treating Doctor #6
Name of Treating Doctor
Address
Phone Number

Area Code Phone Number
Specialty
Date of Care

MonthDay Year
Date
Tests/Treatments

COLLAPSE STOPPER
Previous Accidents
List all treatments for conditions related to previous auto accidents including all hospital stays, doctors visits, MRIs, X-rays, etc.

Most Recent Previous Accident
Date of accident

MonthDay Year
Date
Location
Hospital
Name of Treating Doctor #1
Please list full name, address, phone #, specialty, dates of care and tests/treatments
Name of Treating Doctor #2
Please list full name, address, phone #, specialty, dates of care and tests/treatments
Name of Treating Doctor #3
Please list full name, address, phone #, specialty, dates of care and tests/treatments

COLLAPSE STOPPER

Previous Accident
Date of accident

MonthDay Year
Date
Location
Hospital
Name of Treating Doctor #1
Please list full name, address, phone #, specialty, dates of care and tests/treatments
Name of Treating Doctor #2
Please list full name, address, phone #, specialty, dates of care and tests/treatments
Name of Treating Doctor #3
Please list full name, address, phone #, specialty, dates of care and tests/treatments

COLLAPSE STOPPER
Personal Injury Insurance Information
Patient Name

First Name Last Name
Date of Accident

MonthDay Year
Date
Attorney Name
Attorney Phone #

Area Code Phone Number
Attorney Address

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Your Auto Insurance Info
Company
Policy #
Claim #
Adjuster Name & Phone
Is there Med Pay on your insurance policy?

YesNo
Other Party's Insurance Info
Company
Policy #
Claim #
Adjuster Name & Phone
Health Insurance (info required to collect from Med Pay)
Plan Name: (Aetna, Anthem, Etc.)
Member ID #
Patient Signature

Clear
Notice of Doctor’s Lien
Patient Name*

First Name Last Name
Date of Accident*

MonthDay Year
Date
I do hereby authorize Elite Sports Medicine to furnish you, my attorney, with a full report of examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was recently involved.

I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums as may be due and owing him for the medical service rendered me both by reason of this accident and by reason of any other bills that are due his office and to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect and fully compensate said doctor. And I hereby further give a Lien on my case to said doctor against any and all proceeds of my settlement, judgment, or verdict which may be paid to you, my attorney, or myself; as the result of the injuries for which I have been treated or injuries in connection therewith.

I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service rendered me and that this agreement is made solely for said doctor’s additional protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee.

This lien supersedes any type of pre-paid health insurance plan, which we may contract with. The balance due after payments from your insurance company must be paid from sums collected from any settlement, judgment or verdict, which may be paid to you.

A photocopy of this lien will be considered as valid as the original. This lien is irrevocable and binding to any subsequent Attorney retained by the patient.
Date*

MonthDay Year
Date
Patient’s or Guardian’s Signature*

Clear
Please note: According to California law, it is unlawful to knowingly make a false or fraudulent claim. *Por favor note: de acuerdo con la ley de California, es illegal hacer reclamo falso o fraudulento.

The undersigned being attorney of record for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict, as may be necessary to adequately protect and fully compensate said doctor above-named.
Dated _______________________________

Attorney Signature __________________________________________________
Should be Empty:

AUTOMOBILE ACCIDENT HISTORY

Your Vehicle Information

Other Vehicle Information

Road Conditions

Head restraints, Seat backs

Seat belts and Air bags

Head and Body position

Accident Diagram

Accident description

During the crash

After the crash

Hospital

Current Complaints

Current Accident

Previous Accidents

Personal Injury Insurance Information

Notice of Doctor’s Lien