Auto Accident Only

Please fill in the following info about the vehicles involved:*

	Year	Make	Model
Your car
Other car

Were you:*

DriverPassenger in frontPassenger in back
Were you wearing a seatbelt?

NoYes
If Yes, please specify:

Lap beltShoulder-lap belt
Did the vehicle strike you from:

BehindDriver's sidePassenger sideFront
Were you aware of the approaching collision prior to impact?

NoYesSurprised
Were you facing forward at time of impact:

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

NoYes
If Yes, how long
What was your car doing at time of impact (check all that apply)

StoppedMovingTurningSlowing downSpeeding upTraveling at steady speed
Describe the events of the accident to the best of your knowledge:
Did the police come to the accident?

NoYes
Were you taken to the hospital?

NoYes
If Yes (which one?)
How did you get to the hospital?

SelfAmbulanceDriven by
If Driven by, describe:
Did any part of your body strike any part of your car (steering wheel, windshield, door, etc, after impact?

NoYes
If Yes, describe:

When did you first notice any pain or injury from the accident (describe area of body involved)?

Integrative Spine & Body Medicine