PERSONAL INJURY QUESTIONAIRE
Patient Name:
Today's Date:
-
Month
-
Day
Year
Date
Full Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOB:
-
Month
-
Day
Year
Date
Phone #
Please enter a valid phone number.
Secondary #
Please enter a valid phone number.
Employer:
Employer's Phone #
Please enter a valid phone number.
Your Insurance Company
Policy #
Adjustor's Name:
Adjustor's Phone #
Claim #
Email:
example@example.com
Name of Driver/Other Vehicle:
Insurance Co.
Policy #
Date of Accident:
-
Month
-
Day
Year
Date
Time of Day:
Your position in vehicle:
Driver
Passenger Seat
Back Seat
The impact on your vehicle
Left
Right
Front
Rear
Side
Head-on
The movement of the vehicle you were in:
Stopped
Backing Up
Forward
Turning Left
Turning Right
Check the statement that best describes the speed of your vehicle:
Less than 15MPH
Up to 25MPH
Up to 40MPH
Up to 65MPH
Greater than 65MPH
Unknown
Check the box that best describes the damage to your vehicle:
No visible damage
Moderate visual damage
Slight visible damage
Totaled
Heavy visible damage
The impact to the other vehicle:
Left
Right
Front
Rear
Side
Head-on
Circle the movement of the other vehicle:
Stopped
Backing Up
Forward
Turning Left
Turning Right
Was your vehicle towed from the scene?
Yes
No
Accident Location:
Number of people in your vehicle:
Do you have a police report?
Yes
No
Were police notified?
Yes
No
Did airbags deploy?
Yes
No
Which airbags:
Were you wearing your seat belt?
Yes
No
Did any part of your body hit the vehicle?
Did an ambulance arrive at the scene?
Yes
No
Did they examine you?
Yes
No
Where did you go after the accident?
Home
Hospital
Urgent Care
Other
Have you been treated by another doctor since the accident?
Yes
No
If yes, please list the doctor(s) and their phone number:
What type of treatment did or are you receiving?
Please describe the location of your symptoms at the time of the accident:
Since this injury occurred are your symptoms:
Improving
Getting worse
Same
Please check all that apply:
Dull pain
Sharp pain
Aching
Burning
Shooting
Tight/Stiff
Tingling
Numbness:
Nausea
Muscle Spasm
Pins & Needles:
Palpitations
Rib Pain
Chest Pain
Neck Pain
Depression
Back Pain
Anxiety/Panic
Sleeping Differences
Weakness
Shock
Fatigue
Soreness
Shortness of Breath
Stomach Pain
Disbelief
Stress
Dizziness
Upset
Facial Pain
Tension
Headaches
Loss of Memory
Irritability
Ringing in Ears
Numbness:
Fingers
Toes
Arms
Legs
Other
Pins & Needles:
Fingers
Toes
Arms
Legs
Other
Have you lost time from work as a result of this accident?
Yes
No
Last day worked:
Type of employment:
Present salary:
Are you being compensated for time lost from work?
Yes
No
Type of compensation:
Do you notice any activity restrictions as a result of this injury?
Yes
No
If yes, please describe in detail
Any other pertinent information?
Patient/Guardian Name:
Date:
-
Month
-
Day
Year
Date
Patient/Guardian Signature:
Clear
Submit
Should be Empty: