Automobile Accident History

AUTOMOBILE ACCIDENT HISTORY
Patient Name *

First Name Last Name
Date of Accident *

Month Day 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:

Stopped Slowing Accelerating
If stopped, was your foot on the brake?

Yes No
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:

Stopped Slowing Accelerating
Road Conditions
Road conditions at the time of the accident:

Dry Damp Snow Ice
Visibility conditions at the time of the accident:

Daylight Dawn Dusk Dark
Head restraints, Seat backs
If adjustable, was the position of the headrest altered by the accident?

Yes No
Was the seat back adjustment altered by the accident?

Yes No
Was the seat broken?

Yes No
Seat belts and Air bags
Were you wearing a seatbelt?

Yes No Don't know
What type of seat belt?

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

Yes No
If your air bag deployed, were you struck?

Yes No
Where were you struck by the air bag?
Head and Body position
Which way was your body pointed at the point of impact?

Straight Right Left
Which way was your head pointed at the point of impact?

Straight Right Left
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 wheel Two on wheel N/A
Did you strike any parts of the vehicle?

Yes No
Please describe what parts of the vehicle you struck:
Did you strike any objects after the crash?

Yes No
Please describe what objects you struck:
Were you aware or surprised of the approaching collision?

Aware Surprised
Were you wearing a hat or glasses?

Yes No
Were the hat or glasses still on after the crash?

Yes No
Did you lose consciousness (black out) upon impact?

Yes No
How long did you lose consciousness?
Did you experience a flash of light or explosion in your head?

Yes No
After the crash
Did you become:

Confused Disoriented Light Headed Dizzy Nauseated Blurred Vision Ring/Buzz in ears
Which of these symptoms are you still experiencing?

Confused Disoriented Light Headed Dizzy Nauseated Blurred Vision Ring/Buzz in ears
Are you currently suffering from any of the following:

Restlessness Irritability Difficulty concentrating Difficulty with memory Sleeplessness Forgetfulness Reduced tolerance to heat Reduced tolerance to alcohol
Did the police come to the accident scene?

Yes No
Is there a police report?

Yes No
Hospital
Did you go to the hospital?

Yes No
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?

Medications Cervical collar Ice Pack Follow up
List of medications you were given:
Follow up instructions:
Current Complaints

Please list, in detail, all current symptoms / complaints in order of severity.