Auto Accident Form Name Today’s_Date Date & Time of Accident Were you the: Were you the: Driver Front Passenger Rear Passenger If a traffic violation was issued, if so to whom was it issued? Number of people in the accident vehicle? Did the police come to the accident site? Was a police report filed? Were you wearing your seat belt? Was this vehicle equipped with airbags? if yes did they inflate? In relation to the base of your skull, where was the headrest? In relation to the base of your skull, where was the headrest? Above Below At base of skull What did your vehicle impact? Another vehicle or other (if so please explain) Did any part of your body strike anything in the vehicle? If yes please explain Make and Model of the vehicle you were occupying? Name of location/ street on which you were traveling? In which direction were you headed? In which direction were you headed? North East South West What was the approx. speed of your vehicle? Did the impact to your vehicle come from the: Did the impact to your vehicle come from the: Front Rear Right Side Left Side Other During the impact were you facing: During the impact were you facing: Right Left Forward Were you Aware or surprised by the impact? If accident vehicle made impact with another vehicle what was the make and model of that other vehicle? Direction other vehicle was headed? Direction other vehicle was headed? North East South West Speed of other vehicle if known? In your words please describe the accident Did accident render you unconscious? If yes how long? Please describe how you felt immediately after the accident Have you gone to the hospital or seen any other Doctor? Have you gone to the hospital or seen any other Doctor? If so: when did you go? How did you get there? Name of hospital and / or attending doctor? Describe any treatment you received Were x-rays taken? Was medication prescribed? Have you been able to work since this Injury? Are your work activities restricted as a result of this injury? Indicate the symptoms that are result of this accident: Indicate the symptoms that are result of this accident: Dizziness Memory Loss Headaches Blurred Vision Buzzing in Ear Ears Ringing Difficult Sleeping Irritability Fatigue Tension Neck Pain Stiff Neck Jaw Problems Arms/ Shoulder pain Numb hands/ fingers Chest Pain Shortness of Breath Upset Stomach Nausea Back pain Lower Back Pain Back Stiffness Leg Pain Numb Feet Toes Others Is your condition getting worse? (circle one) Is your condition getting worse? (circle one) Yes No Constant Comes & Goes Have you retained an attorney? If so please provide with his/her phone number Indicate your degree of comfort while performing the following activities: please circle one Indicate your degree of comfort while performing the following activities: please circle one Lying on stomach Lying on stomach comfortable uncomfortable painful Lying on back Lying on back comfortable uncomfortable painful Lying on side Lying on side comfortable uncomfortable painful Sitting Sitting comfortable uncomfortable painful Standing Standing comfortable uncomfortable painful Stretching Stretching comfortable uncomfortable painful Walking Walking comfortable uncomfortable painful Running Running comfortable uncomfortable painful Sports Sports comfortable uncomfortable painful Working Working comfortable uncomfortable painful Lifting Lifting comfortable uncomfortable painful Bending Bending comfortable uncomfortable painful Kneeling Kneeling comfortable uncomfortable painful Pulling Pulling comfortable uncomfortable painful Reaching Reaching comfortable uncomfortable painful To evaluate the effect that continuing work will have on your recover please complete the following: To evaluate the effect that continuing work will have on your recover please complete the following: How many hours are in your normal work day? Please circle your daily job duties and any activities which you are occasionally asked to perform. Please circle your daily job duties and any activities which you are occasionally asked to perform. Standing Sitting Walking Lifting Driving Twisting Crawling Bending Operating Equipment Work with arms above head Typing Others What positions can you work in with minimum physical effort and for how long? Prior to the injury were you capable of working on an equal basis with others you age? Do you work with others who can help you with any heavy lifting? While in recovery is there any light duty work you could request? Submit
