Automobile Accident Forms

Name:

Today's Date:

Accident Date:

What State Did Your Accident Happen?

Who Is Your Attorney?

DESCRIBE THE VEHICLE

Patient's Vehicle Type:

Bus

Sports Car

Coupe

Sedan

Van

Truck

Station Wagon

Pick-up truck

Sport-utility

Vehicle Size:

Compact

Full-size

Mini

Sub-compact

Semi

Position in Vehicle:

Driver

Front mid passenger

Front right passenger

Rear left passenger

Rear mid passenger

Rear right passenger

DESCRIBE THE ACCIDENT

Describe what happened at the time of the accident:

Action of patient vehicle:

Crossing intersection

Stopped at intersection

Stopped for pedestrian

Stopped in traffic

Turning right

Turning left

Traveling speed limit

Faster than speed limit

Slower than speed limit

Patient's Vehicle was hit:

Head-on

On the left front

On the right front

On the left rear

On the right rear

Was rear-ended

Sideswiped on left

Sideswiped on right

Damage:

Complete

Extensive

Moderate

Minimal

Damage to other vehicle:

Complete

Extensive

Moderate

Minimal

Weather Conditions:

Clear

Cloudy

Drizzling

Foggy

Rainy

Snowing

Storming

Sunny

Road Conditions:

Damp

Dry

Dry with icy patches

Iced over

Snowed over

Wet

Time of Day:

The Dawn

The day

Dusk

The night

Visibility:

Fair

Good

Poor

DESCRIBE MOMENT OF IMPACT

Body Position at impact:

Leaning forward

Slouched in Seat

Straight

Turned left

Turned right

Body Position at impact:

Backward then forward

Forward then backward

To the left

To the right

About the vehicle

Outside the vehicle

Under the vehicle

Head position at impact:

Straight

Titled forward

Turned left

Turned right

Direction head was thrown:

Backward then forward

Forward then backward

Side to side

Type of passive restraint

A lap belt

A shoulder belt

A shoulder-lap belt

Did the airbags deploy?

Yes No

Did you brace for impact?

Yes No

Position of head rests:

In the high position

In the low position

In the middle position

Not installed

Additional Notes/Comments:

Did your vehicle go into a spin/roll?

Were brakes being applied?

Your approximate speed during impact?

Other vehicle?

Did you hit anything inside the vehicle during impact?

Head

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Lt Shoulder

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Rt Shoulder

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Lt Arm

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Rt Arm

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Lt Elbow

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Rt Elbow

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Lt Wrist

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Rt Wrist

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Lt Hip

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Rt Hip

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Lt Knee

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Rt Knee

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Lt Ankle

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Rt Ankle

Dashboard

Windshield

Door

Seat

Steering

Ceiling

Window

Did you have any bruises/contusions?

Where?

Post Injury

WHAT HAPPENED IMMEDIATELY FOLLOWlNG THE ACCIDENT?

If other, specify:

Type of emergency care provided?

Bandaging

Bracing

CPR

A neck collar

Splinting

Immediate destination after accident?

To work

Home

To school

To a hospital

To a clinic

To a doctor's office

Who drove you?

Self

A friend

Ambulance

A family member

Police

Taxicab

Father

Mother

Did you lose consciousness?

Yes No Unsure

If yes, for how long?

A few seconds A few minutes Abut 5 minutes About 15 minutes About 30 minutes Less than an hour More than an hour A couple of hours

POST INJURY TREATMENT:

Were you admitted to a hospital?

Yes No

Name of hospital/clinic:

Local Hospital Emergency Room Other (specify)

If other, specify:

Examining Physician:

Date of initial visit:

a few days ago Last week Several weeks ago About a month ago Several months ago

If other, please specify:

Date of discharge:

a few days ago Last week Several weeks ago About a month ago Several months ago

If other, please specify:

Diagnosis of injury:

Select what diagnostic tests were performed at the hospital/clinic?

X-ray

What part of the body?

CT scan

What part of the body?

MRI

What part of the body?

What medications were prescribed?

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