stcacupuncture.com - Auto Accident Form

Motor Vehicle Collision Form
Patients Name:
Date:

MonthDayYear
Date
1) Please choose the date of the MVC:

MonthDayYear
Date
2) Please the time of the MVC:

Hour Minutes

AM/PM Option
3) Please enter the number of vehicles involved in the MVC:

123456789
4) In dollars, please enter the estimated damage to your vehicle
5) What road were you on?
6) What direction were you travelling in?

NWNNEWESWSSE
7) What city & state were you travelling in?
8) Please choose the primary type of impact:

vehicle was rear endedvehicle hit another vehicle from behindvehicle was hit on the passenger’s side
9) What did the vehicle do immediately after the accident?

hit a guardrailhit a treerolled overwas run off the roadOther
10) Where were you sitting in this vehicle?

driverrear left passengerrear passengerfront passengerrear right passengerOther
11) Did you know the accident was coming

was unaware of the impending collisionwas aware the impending collision and she braced herselfwas aware of the collision and relaxedOther
12) What is the type of vehicle you were in?

subcompactcarcompact carmid-size carfull-sized cartruckSUVminivanvanlarger than one ton vehicleOther
13) At the time of impact, your vehicle was:

slowing downgaining speedstoppedmoving at a steady speedOther
14) At impact the other vehicle involved was:

slowing downgaining speedstoppedmoving at a steady speedOther
15) During and after the crash, what happened to your vehicle?

kept going straight kept going straighthitting a car in front of herwas hit by another vehiclespun aroundspun around and hit a stationary objectOther
16) Did you lose consciousness during the accident?

lost consciousness during the accidentremained conscious throughout entire accidentOther
17) How was your head positioned during the accident?

head facing forwardhead turned to the lefthead turned to the righthead facing upwardhead facing downwardhead facing to the right and upwardhead facing to the right and downwardhead facing left and upwardhead facing left and downwardOther
18) How was your torso positioned during the accident?

torso positioned forwardtorso positioned to the lefttorso positioned to the righttorso extendedtorso flexedtorso flexed with right rotationtorso extended with right rotationtorso flexed with left rotationtorso extended with left rotationOther
19) How were your hands positioned during the accident?

left hand on the steering wheelright hand on the steering wheelboth hands on the steering wheelleft hand on dashboardright hand on dashboardboth hands on dashboardhand on the seat in fronthands resting along sidehands on ceiling of the carOther
20) Did your head hit any of the following?

windshieldsteering wheelside doordashboardceilingcarframeanother passengerseatside windowOther
21) Did your face hit any of the following?

windshieldsteering wheelside doordashboardceilingcarframeanother passengerseatside windowOther
22) Did your shoulders hit any of the following?

windshieldsteering wheelside doordashboardceilingcarframeanother passengerseatside windowOther
23) Did your neck hit any of the following?

windshieldsteering wheelside doordashboardceilingcarframeanother passengerseatside windowOther
24) Did your chest hit any of the following?

windshieldsteering wheelside doordashboardceilingcarframeanother passengerseatside windowOther
25) Did your hips hit any of the following?

windshieldsteering wheelside doordashboardceilingcarframeanother passengerseatside windowOther
26) Did your knees hit any of the following?

windshieldsteering wheelside doordashboardceilingcarframeanother passengerseatside windowOther
27) Did your feet hit any of the following?

windshieldsteering wheelside doordashboardceilingcarframeanother passengerseatside windowOther
28) What kind of headrests were in your vehicle?

movable fixed head restraintsfixed, non movable head restraintsno head restraintsOther
29) Where was your headrest positioned on your head?

at the top of the back of headat the middle height of the bad of headat the lower portion of the back of headat the level of the back of neckat the level of the shoulder bladesOther
30) Did you have your seatbelt on?

was wearing a shoulder strap seat beltwas wearing a lap belt seat beltwas in a baby car seatwas not wearing her seatbeltcannot remember is she had a seat belt onwas in a booster seatOther
31) Did you slide out of your seatbelt?

slid out of seatbeltremained in seatbeltpartially slid out of seatbeltOther
32) What was damaged in your vehicle?

windshieldsteering wheeldashboardseat frameside windowrear windowmirrorknee bolsterrear bumpertrunkcompletely totaledfront left doorfront right doorback left doorback right doornoneOther
33) Choose the items that dented inward during the accident?

side doordashboardfloor boardnoneOther
34) Choose the doors that would not open as a result of accident?

side doordashboardfloor boardnoneOther
35) How did you go to the hospital?

ambulancehelicopterpolice cardrove herselfwalkingN/A didn’t go to hospitalOther
36) Please choose the locations of your problems:

headachesjawneckupper backshoulderarmelbowwristhandmid backlow backhiplegskneeanklefootOther
37) Were you hospitalized overnight?

YesNoN/A
38) At the hospital, were you prescribed pain medication?

YesNoN/A
39) Were you prescribed muscle relaxers at the hospital?

YesNoN/A
40) Did you receive stitches for any cuts?

YesNoN/A
41) Did you receive any of the following?

Cervical Collarback braceCervical collar and back bracen/a
42) Which x-rays were taken at the hospital?

skullneckmidbacklowerbackfootarmpelvishipslegkneeshoulderno x-raysOther
43) Was an MRI performed?

skullneckmidbacklowerbackfootarmpelvishipslegkneeshoulderno x-raysOther
44) Did you receive any special imaging?

skullneckmidbacklowerbackfootarmpelvishipslegkneeshoulderno special imagingOther
Should be Empty:

Motor Vehicle Collision Form