DESCRIBE HOW THE CRASH HAPPENED:
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1 MOTOR VEHICLE ACCIDENT FORM (PAGE 1) Patient Name: Date: Date of Injury: Time of Injury: AM PM City where crash occurred: Was the street wet or dry? Wet Dry Street (location) where accident occurred: What is the estimated damage to your vehicle:? $ Who made damage estimates on your vehicle? Who owns the vehicle you were involved in? Yes No Did the police come to the accident scene? Yes No Did the police make a written report? Yes No Were photographs taken of your vehicle? If yes, who took them: DESCRIBE HOW THE CRASH HAPPENED: COLLISION DESCRIPTION-TYPE Check all that apply to you. Indicate which type of automobile accident you were involved in: Single-car crash Two-vehicle crash Three or more vehicles Rear-end crash Side crash Rollover Head-on crash Hit guard rail, tree, or object Ran off the road Other (Describe): DESCRIBE THE VEHICLE YOU WERE IN: Make: Model: Year: Small-sized car Mid-sized car Large-sized car Pick-up truck Van Sport Utility Vehicle 2 Door vehicle 4 Door vehicle Large truck, bus, semi truck Sedan Hatchback Station wagon DESCRIBE THE OTHER VEHICLE Make: Model: Year: unknown Small car Mid-sized car Van Pick-up truck/sports utility Full-sizes car Large truck, bus, semi-truck
2 MOTOR VEHICLE ACCIDENT FORM (PAGE 2) Estimated Crash Speeds: Your Vehicle: Other Vehicle: AT THE TIME OF IMPACT YOUR VEHICLE WAS: Slowing down Gaining speed Stopped with brake engaged Stopped without brake Moving at steady speed AT THE TIME OF IMPACT THE OTHER VEHICLE WAS: Slowing down Gaining speed Unknown speed Stopped Moving at steady speed Other DURING AND AFTER THE CRASH, YOUR VEHICLE: Kept going straight, not hitting anything Kept going straight, hitting car in front Was hit by another vehicle Spun around, not hitting anything Spun around, hitting another car Spun around, hitting object other than car INDICATE IF YOUR BODY HIT SOMETHING OR WAS HIT BY ANY OF THE FOLLOWING: Please draw lines from the body regions on the left side and match to the right side. BODY REGION Head Face Shoulder Arm/Hand Front chest wall Side chest wall Hip/Abdomen Knee Leg Foot OBJECT YOU HAD CONTACT WITH Windshield Side Window Side Door Dashboard Knee bolster/glove compartment Seatbelt Frame of car near windows Roof of window Another occupant/animal Roof Steering wheel/column CHECK IF ANY OF THE FOLLOWING VEHICLE PARTS BROKE, BENT, OR WERE DAMAGED IN YOUR CAR: Windshield Seat frame Knee bolster Steering wheel Side or rear window Brake pedal Dash Mirror Other ALL TYPES OF COLLISIONS Indicate those relevant to your case. YES NO Did any of the front or side structures, such as the side door, dashboard, or floorboard of your Car dent inward during the crash? Did the side door touch your body during the crash? Was the door(s) of your vehicle damaged to a point where you could not open the door? Did your body slide under the seatbelt? Did an airbag deploy in your vehicle during the crash?
3 Were you intoxicated (alcohol) at the time of the crash? MOTOR VEHICLE ACCIDENT FORM (PAGE 3) SEATBELT USAGE AND STEERING WHEEL HAND PLACEMENT: YES NO Were you wearing a seatbelt? If yes, does your seatbelt have a: Lap and shoulder strap, Lap belt only Indicate if you had any portion of your seatbelt positioned behind your back or shoulder. Were you holding onto the steering wheel (driver only) at the time of impact? If yes, indicate where each hand was positioned (Use time clock face as your reference point) Left hand: Not on wheel, Yes, hand at o clock, Hand elsewhere REAR-END COLLISIONS ONLY Answer this section only if you were hit from the rear. Describe your vehicle s head restraint system: Movable/adjustable head restraint No headrests in my vehicle Fixed, non-movable head restraint Bench seat in your vehicle without head restraint Please indicate how your head restraint was positioned at the time of crash (if present): At the top of the back of your head Lower height of the back of your head Level of your shoulder blade Midway height of the back of your head Located at the level of the neck Estimated distance between back of head and front of headrest: BRUISING AFTER THE CRASH YES NO Did your body have any bruising (areas that were visibly black and blue) after the crash? If yes indicate where: AWARENESS AND BODY POSITION DESCRIPTIONS: Check all areas that apply to you. You were unaware of the impending collision. You did not see or hear brakes prior to the impact. You were aware of the impending crash and relaxed before the collision. You were aware of the impending crash and braced yourself. Your body, torso, and head were facing straight ahead. You had your head and/or torso turned at the time of collision: Turned to the left, Turned to the right Describe how far you were turned/twisted and why? You were leaning forward at the time of impact resulting in a gap between your body and the seatback. Your torso and body was positioned normally against the seatback with no gaps due to leaning/twisting.
4 EMERGENCY ROOM AND DISABILITY DATES? (PAGE 4) Patient Name: Dates: YES NO Did you go to the emergency room afterward? If yes, date and time: Name of the emergency room? City: Did you go to the emergency room in the ambulance? If yes, name of ambulance: Did you or another person drive you to the emergency room? Name of person: Were you hospitalized after being seen in Emergency Room? If yes, how many days: Did the emergency room doctor take X-rays? Check what regions x-rays were taken: Skull/Face x-rays Ribs/Chest Neck or Middle back x-rays Collar bone Low back or Hip/Pelvis x-rays Shoulder, Arm or Hand Leg or Foot Other Did the hospital or clinic take MRI or CT of your body? If yes, indicate where taken: Skull Neck Low back or hip/pelvis other Did you have any broken bones/fractures? If yes, where: Did you have a cast put on for any sprain or fracture? If yes, type/location: Did you have any dislocations? If yes, where: Did you have any cuts or lacerations? If yes, where: Did you have any skin abrasions? If yes, where: Did you require any stitching for cuts? If yes, where: Did you have any visible bruises or lumps? If yes, where: Did you have any visible bruises along the shoulder or lap portions of your seatbelt Did the Emergency Room doctor give you any pain medications? Did the Emergency Room doctor give you any muscle relaxants? Did the Emergency Room doctor give you any other medications/prescriptions? Were you told you had a herniated or bulging disc in your neck or back? If yes, where: Were you given a neck collar or back brace to wear? Did you require any surgery after the accident? If yes, describe type and date: Were you hospitalized overnight? If yes, indicate dates hospitalized: HOW SOON DID YOU FIRST NOTICE ANY PAIN OR SORENESS AFTER YOU YOUR INJURY? Less than 24 hours after injury Began 1-7 days after injury Began days after injury IF YOU DID NOT SEE A DOCTOR FOR THE FIRST TIME UNTIL AFTER TWO WEEKS FROM THE INJURY DATE, INDICATE WHY: (Check all that apply only if you had delay in seeing a doctor) No pain was noticed No appointment schedule available Thought pain would go away No transportation Work/home schedule conflicts Other: DISABILITY-HAVE YOU BEEN ABLE TO WORK SINCE INJURY? YES NO Have you lost days off work? If yes, you were off work: Partially Completely Please list all dates off work: From: to. If you had neck and/or back pain so severe that you were unable to get out of bed, how many hours after the accident did you develop this disabling level of pain? Hours.
5 POST-TRAUMATIC SYMPTOM QUESTIONNAIRE (PAGE 5) PATIENT INSTRUCTIONS: It is important for this section to be filled out in detail. Look at each symptom listed in the left column and make a single check mark or several check marks in the appropriate columns for the specific symptom which applies to you. Be certain to indicate when you had the beginning of any of the following symptoms. Leave the row blank if the symptom does not apply to you. SYMPTOM LIST Headache/migraine Dizziness Tinnitus (ear ringing) Blurry vision Memory problems Poor concentration Irritability Balance problems Loss of coordination Sensitivity to sound Sensitivity to light Fatigue Anxiety Pain/difficulty swallowing Jaw pain/soreness Neck pain/soreness/aching Neck stiffness Shoulder pain/stiffness Arm pain/tingling/numbness Wrist/hand/finger pain/numbness Weakness in arms/legs Upper/middle back pain/soreness Rib cage pain Low back pain/soreness/aching Hip pain Leg pain Leg numbness/tingling Pain shoots down back of leg Pain primarily in front of thighs Knee pain Ankle/foot pain Other BEGAN IN LESS THAN 24 HOURS AFTER INJURY BEGAN 1 TO 7 DAYS AFTER INJURY YOU HAVE SYMPTOMS CURRENTLY HAD SIMILAR SYMPTOMS WITHIN ONE YEAR BEFORE THIS INJURY
6 PROVIDERS SEEN SINCE INJURY OR WHEN CONDITION BEGAN (PAGE 6) Start with the first doctor you went to after your injury or condition began and list all providers (all types of doctors or therapists) up to your last provider seen and check all that apply for each. Be certain to list these in sequence from first to last. (1) Name Emergency Room, hospital/doctor/therapist/center: Address: Date: Indicate what was done: Exam-consultation Rehabilitation Exercises IME exam or consult only Ultrasound Acupuncture X-ray of neck Spinal adjustments Injection (s) X-ray of chest/mid back Muscle massage/myotherapy Wrist brace-splint X-ray of low back Muscle stimulation Neck collar (brace) Other X-rays Physical therapy Low back brace MRI/CT scan Anti-inflammatory medications Heat packs EMG/ Nerve conduction study Pain medications Ice packs Other tests Muscle relaxants Other Indicate if treatment with this provider: Helped Did not help Other (2) Name Emergency Room, hospital/doctor/therapist/center: Address: Date: Indicate what was done: Exam-consultation Rehabilitation Exercises IME exam or consult only Ultrasound Acupuncture X-ray of neck Spinal adjustments Injection (s) X-ray of chest/mid back Muscle massage/myotherapy Wrist brace-splint X-ray of low back Muscle stimulation Neck collar (brace) Other X-rays Physical therapy Low back brace MRI/CT scan Anti-inflammatory medications Heat packs EMG/ Nerve conduction study Pain medications Ice packs Other tests Muscle relaxants Other Indicate if treatment with this provider: Helped Did not help Other (3) Name Emergency Room, hospital/doctor/therapist/center: Address: Date: Indicate what was done: Exam-consultation Rehabilitation Exercises IME exam or consult only Ultrasound Acupuncture X-ray of neck Spinal adjustments Injection (s) X-ray of chest/mid back Muscle massage/myotherapy Wrist brace-splint X-ray of low back Muscle stimulation Neck collar (brace) Other X-rays Physical therapy Low back brace MRI/CT scan Anti-inflammatory medications Heat packs EMG/ Nerve conduction study Pain medications Ice packs Other tests Muscle relaxants Other Indicate if treatment with this provider: Helped Did not help Other
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