This website is managed by digital marketing agency sembird.

l

Ut wisi enim ad minim veniam, quis laore nostrud exerci tation ulm hedi corper turet suscipit lobortis nisl ut

+080024667921
housemed@mikado.com
34th Avenue New York, W2 3XE

Recent Posts

    Sorry, no posts matched your criteria.

Contact Us For Help

  • No products in the cart.
  • No products in the cart.
Image Alt

Auto Accident Injury Intake Form

Automobile Accident Questionnaire

Patient's Name:
Field is required!
Field is required!
Date of Accident:
Field is required!
Field is required!
Today's Date:
Field is required!
Field is required!

The following questions pertain to you and the vechile you were in:

Vehicle Type:
Field is required!
Field is required!
Vehicle Size:
Field is required!
Field is required!
Your position in the vehicle:
Field is required!
Field is required!
Speed of your vehicle:
Field is required!
Field is required!
Why Vehicle was slowed or stopped:
Field is required!
Field is required!
Collision Type:
Field is required!
Field is required!

The following questions concern the other vehicle involved in the accident:

Vehicle Type:
Field is required!
Field is required!
Vehicle Size:
Field is required!
Field is required!

CONDITIONS AT THE TIME OF THE ACCIDENT:

Time of day:
Field is required!
Field is required!
Road Conditions:
Field is required!
Field is required!
Visibility:
Field is required!
Field is required!
Visibility compromised by:
Field is required!
Field is required!

THE FOLLOWING QUESTIONS CONCERN THE MOMENT OF IMPACT OF THE ACCIDENT:

Were you...
Field is required!
Field is required!
Restraints: (check all that apply)
Field is required!
Field is required!
If you were the driver of the vehicle, was your foot on the brake pedal?
Field is required!
Field is required!
Was the air bag deployed?
Field is required!
Field is required!
What position was YOUR headrest in?
Field is required!
Field is required!
Position of YOUR head at time of impact?
Field is required!
Field is required!
Was your head thrown...?
Field is required!
Field is required!
Position of Your body at time of impact?
Field is required!
Field is required!
Was your body thrown...?
Field is required!
Field is required!
Damage to vehicle YOU were in:
Field is required!
Field is required!
Citations:
Field is required!
Field is required!

AS A RESULT OF THE FORCE OF THE COLLISION, WHICH OBJECTS IN THE VEHICLE DID YOUR BODY STRIKE?

Head
Field is required!
Field is required!
Left Arm
Field is required!
Field is required!
Right Arm
Field is required!
Field is required!
Torso
Field is required!
Field is required!
Left Leg
Field is required!
Field is required!
Right Leg
Field is required!
Field is required!

THE FOLLOWING QUESTIONS CONCERN THE TIME PERIOD IMMEDIATELY FOLLOWING THE ACCIDENT:

Did you lose consciousness?
Field is required!
Field is required!
Immediately following the accident, did you feel...?
Field is required!
Field is required!
Were you able to walk unaided?
Field is required!
Field is required!
Where did you go...?
Field is required!
Field is required!
Next day discomfort...?
Field is required!
Field is required!
Did your major complaints exist before the accident?
Field is required!
Field is required!
In what areas did you IMMEDIATELY feel pain?
Field is required!
Field is required!
Shoulder
Field is required!
Field is required!
Arm
Field is required!
Field is required!
Elbow
Field is required!
Field is required!
Wrist
Field is required!
Field is required!
Hand
Field is required!
Field is required!
Fingers
Field is required!
Field is required!
Buttock
Field is required!
Field is required!
Hip
Field is required!
Field is required!
Thigh
Field is required!
Field is required!
Knee
Field is required!
Field is required!
Calf
Field is required!
Field is required!
Ankle
Field is required!
Field is required!
Foot
Field is required!
Field is required!
Toes
Field is required!
Field is required!
In what areas did you IMMEDIATELY feel pain?
Field is required!
Field is required!
Shoulder
Field is required!
Field is required!
Arm
Field is required!
Field is required!
Elbow
Field is required!
Field is required!
Wrist
Field is required!
Field is required!
Hand
Field is required!
Field is required!
Fingers
Field is required!
Field is required!
Buttock
Field is required!
Field is required!
Hip
Field is required!
Field is required!
Thigh
Field is required!
Field is required!
Knee
Field is required!
Field is required!
Calf
Field is required!
Field is required!
Ankle
Field is required!
Field is required!
Foot
Field is required!
Field is required!
Toes
Field is required!
Field is required!
At the hospital, what areas were x-rayed?
Field is required!
Field is required!
Shoulder
Field is required!
Field is required!
Arm
Field is required!
Field is required!
Elbow
Field is required!
Field is required!
Wrist
Field is required!
Field is required!
Hand
Field is required!
Field is required!
Fingers
Field is required!
Field is required!
Buttock
Field is required!
Field is required!
Hip
Field is required!
Field is required!
Thigh
Field is required!
Field is required!
Knee
Field is required!
Field is required!
Calf
Field is required!
Field is required!
Ankle
Field is required!
Field is required!
Foot
Field is required!
Field is required!
Toes
Field is required!
Field is required!
Where did you experience pain on the day FOLLOWING the accident?
Field is required!
Field is required!
Shoulder
Field is required!
Field is required!
Arm
Field is required!
Field is required!
Elbow
Field is required!
Field is required!
Wrist
Field is required!
Field is required!
Hand
Field is required!
Field is required!
Fingers
Field is required!
Field is required!
Buttock
Field is required!
Field is required!
Hip
Field is required!
Field is required!
Thigh
Field is required!
Field is required!
Knee
Field is required!
Field is required!
Calf
Field is required!
Field is required!
Ankle
Field is required!
Field is required!
Foot
Field is required!
Field is required!
Toes
Field is required!
Field is required!
Submit