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Auto Injury Form
AUTO INJURY PATIENT QUESTIONNAIRE
Patient Information
Today's Date *
First Name *
M.I.
Last Name *
Sex (M/F)
Male
Female
Date of Birth
Social Security #
Date of Injury/Accident *
Address
City
State
ZIP
Home Phone
Work Name
Work Address
Work Phone
Immediate Supervisor
What type of work do you do?
Name of Spouse
Nearest Relative
Accident Details
In your own words, describe the accident *
What was your position in the vehicle?
Driver
Front Passenger
Rear Left Passenger
Rear Right Passenger
What type of vehicle were you driving?
What speed were you traveling?
mph
Who hit you?
I was struck by another vehicle
I hit another vehicle
I hit a stationary object
Where was your vehicle hit?
What type of vehicle hit you?
What speed was the other vehicle traveling?
mph
What part of the other vehicle hit you?
Were you wearing seatbelts?
Yes
No
Position of headrest
Behind head
Behind neck
Behind shoulders
No headrest
Position of head
Straight forward
Turned right
Turned left
Looking
Up
Down
Position of hands
On steering wheel
Other
Position of body
Sitting upright
Turned
Other
How many people were in your vehicle?
Please give the names of any others in the vehicle:
Were there any others injured in your vehicle?
Yes
No
Were there any casualties?
Yes
No
Police called?
Yes
No
Police report?
Yes
No
Was anyone given a citation?
Yes
No
Did airbags deploy?
Yes
No
Were you prepared for impact?
Yes
No
Impact preparedness
I was completely surprised
I saw the collision coming
I saw the collision coming and braced appropriately
What position was your body in just prior to the accident?
What happened to your body at the moment of impact?
How You Felt Physically
During the accident
Immediately after the accident
The next day
Presently
What was your mental/emotional state immediately after the accident?
Medical Attention
Did you receive medical attention at the scene?
Yes
No
Where did you go immediately after the accident?
Did you go to the hospital?
Yes
No
Have you seen any other doctors since the accident?
Yes
No
Did any part of your body hit any of the following?
Dashboard (what body part?)
Windshield (what body part?)
Steering wheel (what body part?)
Right door (what body part?)
Left door (what body part?)
Seat headrest (what body part?)
Unknown object (what body part?)
Symptoms Since the Accident
Since the accident, have your symptoms:
Improved
Worsened
Stayed the same
Please check any symptoms you have noticed (select all that apply)
Headaches
Foot pain/numbness
Cold Hands
Loss of taste
Neck pain
Head heaviness
Upset stomach
Loss of smell
Upper/mid back pain
Neck stiffness
Diarrhea
Anxiety
Lower back pain
Back stiffness
Constipation
Sleeping problems
Chest Pain
Pins/needles in arms
Fainting
Tension
Arm pain/numbness
Pins/needles in hands
Blurred vision
Irritability
Hand pain/numbness
Pins/needles in legs
Buzzing/ringing in ears
Leg pain/numbness
Pins/needles in feet
Loss of balance
Areas of your everyday activities affected (select all that apply)
Sleeping
Standing from sitting
Lifting (heavy, medium, light)
Smelling
Eating
Standing
Driving a car
Tasting
Bathing
Walking
Riding in a car
Housework
Getting dressed
Sitting
Vision
Going to the bathroom
Exercise
Feeling
Typing on a keyboard
Running
Emotional stability
Lifestyle
Were you pregnant at the time?
Yes
No
Describe your lifestyle BEFORE the accident
Active
Moderately active
Inactive
Describe your lifestyle SINCE the accident
Active
Moderately active
Inactive
Describe any other physical changes you've noticed
Activities you used to do BEFORE the accident (select all that apply)
Job
Volunteer Work
Hunting
Second Job
Exercise
Fishing
Crafting
Dance
Yard work
Housework
Sports
Marital relations
Carrying/playing with children
How have your injuries affected your ability to do these activities?
Insurance Information
Responsible Party's Insurance
Name
Phone #
Address
Policy #
Claim #
Health Insurance
Name of Insurance Company
Phone #
Policy #
Group #
Name of Insured
Car Insurance
Name
Adjuster's Name
Address
Phone #
Policy #
Attorney Information
Attorney Name
Address
City
State
Phone
Patient Signature *
Sign here with your finger or stylus
Date
Guarantor (if patient is a minor)
Submit Questionnaire