Auto Injury Form

What was the date of accident?
What time did it occur?
How many vehicles were involved in the accident?
What was the esitmated damage to the vehicle you were in?
What State did the accident occur in?
What city did the accident occur in?
What intersection or street were you on when the accident occured?
What direction were you traveling?
What type of impact was the accident?
Did your vehicle hit anything after the accident?
Where were you sitting in the vehicle during ur accident?
Did you know the accident was coming?
What type of vehicle were you in?
What type of vehicle impacted yours?
At the time of the impact, how fast was your vehicle moving?
At the time of impact, how fast was the other vehicle moving?
During and after the crash what happened to your vehicle?
Kept going straight
Kept going straight hitting the car in front
Spun Around
Was hit by another vehicle
Spun around and hit a stationary object
Hit a stationary object
Did you lose consciousness during the accident?
Yes
No
How was your head positioned during the accident?
How was your torso positioned during the accident?
How were your hands positioned during the accident?
Did your head hit anything during the accident?
Did your face hit anything?(No or Yes , the please describe.)
Did your shoulders hit anything during the accident? No or Yes, then please describe
Did your neck hit anything during the accident?(No or Yes, then please describe.)
Did your chest hit anything during the accident?(No or Yes, then please describe.)
Did your hips hit anything during the accident?(No or Yes, then please describe.)
Did your knees hit anything during the accident?(No or Yes, then please describe.)
Did your feet hit anything during the accident?(No or Yes, then please describe.)
What Kind of headrest was in your vehicle?
Movable fixed headrest
nonmovable fixed headrest
No headrest
Where was the headrest postioned on your head?
Did you have your seatbelt during the accident?
Yes
No
What was damaged in your vehicle? (Select all that apply)
Dashboard
Windshield
Seat Frame
Side Window
Rear Window
Front Bumper
Trunk
Steering Wheel
Rear Bumper
Front Left Door
Back Left Door
Front Right Door
Back Right Door
Knee Bolster
Mirror
Completely Totalled
Choose the items that dented inward?
Floorboards
Side door
Dashboard
Choose the door that would not open as a result of the accident
Front Left
Read Left
Front Right
Rear Right
Did you go to the hosptial? If no, why and do not anwser 38-43
What was the name of the hosptial?
How did you get to the hosptial?
Were you hosptialized over night?
Select what you prescribed at the hosptial
Pain Medication
Muscle Relaxors
Neck Brace
Did you recieve any stiches for any cuts at the hospital?
Were X rays taken at the hospital? If yes, which are was taken?
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