MOTOR VEHICLE COLLISION/PERSONAL INJURY QUESTIONNAIRE
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1 MOTOR VEHICLE COLLISION/PERSONAL INJURY QUESTIONNAIRE Please answer all questions completely: 1. Your name and address: 2. Phone Number: 3. In your own words, please describe the accident: 4. Where did the accident occur? City/Town: State: 5. Date of accident: Time: AM PM 6. Were you the: driver passenger pedestrian 7. If you were the passenger, were you in the front seat right rear seat left rear seat 8. What type of vehicle were you in? 9. What type was the other vehicle? 10. Did your vehicle strike the other vehicle? yes 11. Was your car struck by the other vehicle? yes 12. What direction was your vehicle going? 13. What direction was the other vehicle going? 14. Was the impact from: the front the rear the left side the right side 15. What was the approximate speed at the time of the impact? Your vehicle mph Other vehicle mph 16. What was the weather at the time of the accident? dry wet 17. Was your vehicle in: park neutral in gear moving stopped 18. Were your brakes being applied? yes 19. Was your vehicle pushed: forward backward sideways 20. Were you pushed: forward backward Page 1 of 5
2 21. Did your seat have a head restraint (headrest)? yes If yes, what was the position of the headrest: low mid-position high 22. Did your head bend over the headrest? yes 23. Did your hat/glasses end up in the back seat or near the rear window? yes 24. Did any other part of your body hit the interior of the vehicle? yes If yes, please specify: seatbelt restraints steering wheel dashboard windshield side door side window other 25. Which part of your body hit the interior of the vehicle? chest head chin face R - L knee R - L shoulder R - L hand other 26. Were you holding onto the steering wheel? yes 27. Did you brace your arms? yes 28. Did you brace your legs against the floorboard? yes 29. Was your ankle turned? yes 30. Did the vehicle go into a spin or roll as a result of the impact? yes If yes, explain: 31. How much damage was there to the outside of the vehicle? ne some a lot 32. How much damage was there to the inside of the vehicle? ne some a lot 33. At the point of impact, did you experience pain? Be specific: 34. Immediately after the accident were you: conscious dazed unconscious 35. If you lost consciousness, how long? 36. Were you wearing a seat belt? yes 37. Did the belt have a shoulder harness? yes If yes, did it contribute to the pain you are experiencing? yes 38. At the time of impact were you: looking straight ahead looking to the right looking to the left looking down looking up 39. Did the seat break as a result of the impact? yes 40. Were you surprised by the impact? yes Page 2 of 5
3 41. Did you go to the hospital? yes If yes, when? right after the accident next day other If yes, how did you get there? ambulance other: 42. If transported by ambulance, did the ambulance attendants place you in a: neck brace back brace other 43. Was any medication or medical supplies given? 44. Did you have x-rays taken at the hospital? yes If you went to the hospital, please answer the following: Name of hospital Name of doctor Diagsis Treatment Received 45. Have you had any similar problems before? yes If yes, explain: 46. Are you diabetic? yes 47. Do you have high blood pressure? yes 48. Do you have low blood pressure? yes 49. Do you have arthritis or degenerative joint disease? yes 50. What type of work do you do? 51. What are your job requirements? 52. Have you lost any days of work from your injury(ies)? yes If yes, give dates: Patient Signature Date Witness Date Print Name Page 3 of 5
4 PERSONAL INJURY INSURANCE COVERAGE Date Spoke With Number Patient Name Insurance Company Insured Name Date of Accident Claim Number Policy Number Has the accident been reported? yes Name of adjuster handling claim Will insurance company accept assignment of benefits? yes If t, will they make checks payable to patient and our office? yes GROUP HEALTH INSURANCE Do you have medical benefits under your auto insurance? yes Insurance Company Insured Name Agent Policy# Phone Name and address of other party or parties involved in accident: Page 4 of 5
5 ATTORNEY INFORMATION Date Spoke With Number Patient Name Attorney Name Does your attorney need copies of the bills? yes In the event of settlement, will they protect any unpaid balance? yes Do they have PIP? yes Do we file? yes Do they have insurance? yes Do we file? yes Can we file liability? yes Page 5 of 5
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