brookevillechiropractic.com - AUTOMOBILE ACCIDENT HISTORY FORM

Your Name:

Today’s Date:

Date

Your auto insurance information:

Insurance company:

Phone:

Please enter a valid phone number.

Agent/Adjusters Name:

Claim #:

Attorney’s Name:

Phone:

Please enter a valid phone number.

The At Fault’s Auto insurance information:

Insurance Company:

Phone:

Please enter a valid phone number.

Agent/Adjuster’s Name:

Claim #:

Date of Accident:

Date

Time of Accident:

am/pm

City & Street of Accident:

Road Conditions at the time of the accident:

WETDRYICYOTHER

Did the police come to the accident scene?

YesNo

Is there a report?

YesNo

Did you go to a hospital?

YesNo

If yes, what is the name and city of the hospital?

How did you get to the hospital?

What parts of your body were x-rayed at the hospital?

What did the hospital do for your injuries?

How long did you stay at the hospital?

What bleeding cuts did you sustain during this accident?

What bruises did you sustain during this accident?

Where were you seated in the vehicle?

Were you aware of the approaching collision prior to impact, or did impact catch you by surprise?

AWARESURPRISE

Did you lose consciousness (black out) upon impact?

YESNO

How long?

Did you experience a flash of light or explosion in your head?

Did you become

If you still have some of those symptoms, which ones?

Are you currently suffering from any of the following (please check):

How far is the top of the headrest or seatback from the top of your head (approximately)?

Inches ABOVE or BELOW

Were you wearing a seatbelt?

YESNO

If yes, was it a lap seatbelt_____ or shoulder-lap seatbelt

List the year, make and model of the vehicle you were in: (Year, make and model)

Was your car stopped at the time of impact?

YESNO

If yes, was the driver’s foot also on the brake?

YESNO

If no, then estimate the speed of the vehicle you were in:

mph

If your vehicle was moving at the time of impact, was it: (please select)

Slowing downGaining speedTraveling at a steady rate of speed

On what part of the automobile did your following body parts hit?

Did you receive any injury or bruise from the seat belt?

YESNO

If YES, then describe:

What is the estimated cost damage to the vehicle you were in?

$

Which of the following car parts broke during the accident?

Was the trunk of your body pointed straightforward at the time of the collision?

YESNO

If no, how was it turned?

Was your head pointed straightforward?

YESNO

If no, what direction was it turned and by how much?

What is the year, make and model of the other vehicle?(Year, make and model)

Was the other vehicle moving at the time of the collision?

YESNO

If yes, what was its approximate speed?

Mph

If the other vehicle was moving at the time of the collision, was it (please select):

Slowing downGaining speedTraveling at a steady speed

Please describe, to the best of your knowledge, what happened during this accident:

AUTOMOBILE ACCIDENT HISTORY FORM

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