AUTOMOBILE  ACCIDENT  HISTORY  FORM

Your Name ___________________________________    Today's Date ___________________

Date of Accident _________________________                Time of Accident ______________am/pm

City of Accident _________________________                 Street of Accident ___________________

Road conditions at the time of the accident:  WET    DRY    ICY    OTHER ____________________

Did the police come to the accident scene?   YES       NO   Is there a report?   YES       NO

Did you go to a hospital?   YES       NO

If yes, what is the name and city of the hospital? _____________________________________

How did you get to the hospital? __________________________________________________

What parts of your body were X-rayed at the hospital? ________________________________

What were the findings of your X-rays? ____________________________________________

What did the hospital do for your injuries? __________________________________________

How long did you stay at the hospital? _____________________________________________

What bleeding cuts did you sustain during this accident? _________________________________

What bruises did you sustain during this accident? ______________________________________

Where were you seated in the vehicle?   DRIVER         PASSENGER         BACKSEAT         OTHER

At the moment prior to the collision, were you:  AWARE      or     CAUGHT  BY SURPRISE

Did you lose consciousness (black out) after impact?   YES          NO How long? ___________________

Did you experience a flash of light or explosion in your head?            YES                 NO

From the accident     CONFUSED              DISORIENTED             LIGHT  HEADED/DIZZY

Did you become?      NAUSEATED            BLURRED VISION       RING/BUZZ  IN  EARS

If you still have any of those symptoms, which ones? ______________________________________

Are you currently suffering from any of the following  (please circle)?

DIFFICULT  CONCENTRATING               FORGETFULNESS               SLEEPLESSNESS

When did your spine-related symptoms (pain) begin, after the accident? ________________________

What is the approximate distance from the back of your head and the vehicle’s headrest? _______ inches

Did your head go back over the top of your vehicle’s headrest, after the impact?      YES                 NO

Were you wearing a seatbelt?     YES                 NO

If yes, was it a:     LAP  SEATBELT     or     SHOULDER-LAP  SEATBELT

Does your vehicle have an airbag?             YES                 NO

Did the airbag deploy in this accident?            YES                 NO

Did you receive an injury from the airbag?            YES                 NO

Please describe: ________________________________________________________________

List the year, make and model of the vehicle you were in:

year ________________   make __________________     model ____________________

Was your car stopped at the time of impact?                 YES                 NO

If yes, was the driver's foot also on the brake?      YES                 NO

If no, then estimate the speed of the vehicle you were in: __________ mph

If your vehicle was moving at the time of the collision, was it (please circle):

SLOWING  DOWN             GAINING  SPEED             TRAVELING  AT A  STEADY  SPEED 

On what part of the automobile did your following body parts hit?

head hit ____________________________  chest hit _________________________________

right/left shoulder hit __________________  right/left arm hit __________________________

right/left hip hit ______________________   right/left leg hit ___________________________

right/left knee hit _____________________   other ___________________________________

Did you receive any injury or bruise from the seatbelt?     YES     NO

If yes, then describe: ____________________________________________________________

What is the estimated damage cost to the vehicle you were in?    $_____________________________

Which of the following car parts were damaged from the accident? (please circle)

windshield     front seat back

right/left side window     steering wheel

exterior: FRONT,  BACK,  SIDE,  FRAME      other ________________________________

Was the trunk of your body pointed straight forward at the time of the collision?

YES    NO  If no, how was it turned?_______________________________________

Was your head pointed straight forward?   YES     NO 

If no, what direction was it turned and by how much?

___________________________________________________________________

List the year, make and model of the other vehicle?

year ________________   make __________________     model ____________________

Was the other vehicle moving at the time of the collision?     YES       NO

If yes, what was its approximate speed? ___________mph

If the other vehicle was moving at the time of the collision, was it (please circle):

SLOWING  DOWN      GAINING  SPEED    TRAVELING  AT A  STEADY  SPEED

Please describe, to the best of your knowledge, what happened during the accident:

______________________________________________________________________________

______________________________________________________________________________

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