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:  WETDRYICYOTHER ____________________
Did the police come to the accident scene?  YESNO;  Is there a report?  YESNO
Did you go to a hospital?  YESNO
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?  DRIVERPASSENGERBACKSEATOTHER
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  CONFUSEDDISORIENTEDLIGHT HEADED/DIZZY did you become?   NAUSEATEDBLURRED VISIONRING/BUZZ IN EARS
If you still have any of those symptoms, which ones? ______________________________________
Are you currently suffering from any of the following (please circle)? DIFFICULTLY CONCENTRATINGFORGETFULNESSSLEEPLESSNESS
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? _______ in.
Did your head go back over the top of your vehicle’s headrest, after the impact?  YES  NO
Were you wearing a seatbelt?  YESNO
If yes, was it a:  LAP SEATBELT  OR  SHOULDER-LAP SEATBELT
Does your vehicle have an airbag?  YESNO Did the airbag deploy in this accident?  YESNO Did you receive an injury from the airbag? YESNO
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? YESNO
IF yes, was the driver's foot also on the brake? YESNO
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 DOWNGAINING SPEEDTRAVELING 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?  YESNO
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?
YESNO; If no, how was it turned?_______________________________________________
Was your head pointed straight forward? YESNO; 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 DOWNGAINING SPEEDTRAVELING AT A STEADY SPEED
Please describe, to the best of your knowledge, what happened during the accident:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________