Motor Vehicle Accident Questionnaire Form
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1
2MOTOR VEHICLE ACCIDENT QUESTIONNAIRE
Name:____________________________Date of Birth: _______________________ Date of Accident___________________________
Address:____________________________________
Postal Code:_____________
E-mail address:_________________
H. Phone:(
)_______________________
W. Phone:(
)_________________ C. Phone: (
)_________________
Occupation:___________________ Employer:__________________________________
Referred by:___________________
Where did the accident happen? Describe the accident in your own words:
What was your position in the car?
DRIVER: If driver, were your hands on the steering wheel?
Left
Right
Both
PASSENGER: If passenger, were you sitting in
Front
Right Rear
Left Rear
Did your vehicle strike another vehicle
Yes
No
Was your vehicle struck by another vehicle
Yes
No
Angles of impact… First Collision:
Front
Back
Left
Right
If Second Collision:
Front
Back
Left
Right
Where you wearing a seat belt?
Yes
No
Did you brace for impact?
Yes
No…
I braced with my
I braced with my feet
hands
Which way were you facing at the time of impact?
Left
Right
Straight ahead
Did you strike anything in vehicle at time of impact?
Yes
No
If yes, specify what part of your body struck what:ie…head chest chin shoulder Right /Left Knee
Steering Wheel______________________
Dashboard__________________________
Windshield_________________________
Roof_______________________________
Left Side Door ______________________
Right Side Door _____________________
Left Side Window____________________
Right Window_______________________
Other______________________________________________________________________________
Did the seat back bend? break?
Yes
No
Immediately following the accident, how did you feel?
dizzy/dazed
disoriented
unconscious
nervous
nauseous
upset
weak
Other _______________________________________________
Did you go to the hospital?
Yes
No
Were you admitted to the hospital?
Yes
No
If yes how long?_____
If you went to the hospital, when?
At time of accident
Next day
How did you get to the hospital?
Ambulance
Police car
Private Transportation
Name of Hospital:____________________________________________________
Attended by Dr.______________________________________________________
… what treatment was given?
NONE
x-rayed
given stitches
bandaged
placed in a cervical collar
given pain medication
given instructions regarding concussions
given instructions regarding sprains and strains
Physical Therapy
instructed to call a Orthopedic Surgeon
instructed to call a private physician
referred to this office for treatment
Other
______________________________________________________________________________________________________
Have you seen any other doctor as a result of this accident?
Yes
No
Doctor's name:______________________________________
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