Automobile Accident Questionnaire

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Emory Miles
5 years ago
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1 Automobile Accident Questionnaire Name Date of accident Today's Date The following questions pertain to you and the vehicle you were in: VEHICLE TYPE: VEHICLE SIZE: Car Pickup Subcompact Van Truck Compact Mini Station Wagon Bus Mid-Size Light Other Heavy Other YOUR POSITION IN THE VEHICLE: Driver Passenger Left Middle Right Front Passenger Rear Passenger Third Seat (rear) Other (please specify SPEED OF YOUR VEHICLE: Stopped Moving Moderately Parked Moving Fast Slowing o Moving at apprx MPH Moving Slowly WHY VEHICLE WAS SLOWED OR STOPPED: Traffic Signal Parking Stop Sign Pedestrian Traffic Busy Intersection COLLISION TYPE: Driver Side Impact Head-on Collision Front Impact Passenger Side Impact Rear Impact Pedestrian Incident The following questions concern the other vehicle involved in the accident: VEHICLE TYPE: VEHICLE SIZE: Car Pickup Subcompact Full-Size Van Truck Compact Mini Station Wagon Bus Mid-Size Light Other Heavy Other

2 Conditions at the time of the accident: TIME OF DAY: ROAD CONDITIONS: VISIBILITY: Full Daylight o Dry Excellent Dawn Damp Good Dusk o Wet Fair Night Snow-covered o Poor Ice-covered Patchy ice/snow VISIBILITY COMPROMISED BY: Brightness Darkness Fog Rain Snow Traffic The following questions concern the moment of impact of the accident: WERE YOU... Unaware that the accident was impending Aware that the accident was impending Aware that the accident was impending and braced for it RESTRAINTS: Seat belt Shoulder harness restraints If were the driver of the vehicle. was your foot on the brake pedal? No o Knocked off by impact WAS THE AIR BAG DEPLOYED? Car not equipped with airbag Air WHAT POSITION WAS YOUR HEADREST IN? High position Middle position Low position POSITION OF YOUR HEAD AT IMPACT? Facing straight ahead Tilted forward o Rotated to the left Rotated to the right bag deployed Air bag not deployed WAS YOUR HEAD THROWN? Backward and then forward To the left To the left, then the right Forward and then backward To the right To the right, then the left POSITION OF YOUR BODY AT TIME OF IMPACT: Straight Tilted forward Rotated to the left Rotated to the right WAS YOUR BODY THROWN? Backward and then forward To the left then the right Across the vehicle Under the vehicle Forward and then backward To the right then the left Outside of the vehicle To the left To the right

3 DAMAGE TO THE VEHICLE YOU WERE IN: Incurred minimal damage Incurred severe damage Incurred moderate damage Was totaled t known CITATIONS: ne issued Yourself Driver of vehicle in which you were passenger Driver of other vehicle t sure As a result of the force of the collision, which objects in the vehicle did your body strike? HEAD: LEFT ARM: Steering wheel Right door Steering wheel Right door o Dashboard Left window Dashboard Left window Armrest o Console Armrest Console Rear view mirror o Front seat Rear view mirror Front seat Left door Backseat Left door Backseat RIGHT ARM: TORSO: Steering wheel o Right door Steering wheel o Right door Dashboard Left window Dashboard Left window Armrest o Console Armrest Console Rear view mirror Front seat Rear view mirror Front seat Left door Backseat Left door Backseat LEFT LEG: RIGHT LEG: Steering wheel Right door Steering wheel Right door Dashboard Left window Dashboard Left window Armrest Console Armrest Console Rear view mirror Front seat Rear view mirror Front seat Left door Backseat Et Left door Backseat The following questions concern the time period immediately following the accident: DID YOU LOSE CONSCIOUSNESS? IMMEDIATELY FOLLOWING THE ACCIDENT DID YOU FEEL...? Dizzy Weak Dazed Nervous Disoriented Nauseated

4 WERE YOU ABLE TO WALK UNAIDED? WHERE DID YOU GO...? Drove home Was driven home Was driven to work Drove to hospital Drove to school Was driven to school Drove to work Was driven to hospital Taken to hospital by ambulance NEXT DAY DISCOMFORT...? Increased Decreased Same DID YOUR MAJOR COMPLAINTS EXIST BEFORE THE ACCIDENT? IN WHAT AREAS DID YOU IMMEDIATELY FEEL PAIN? Head Shoulder ( Left Right) Hip ( Left Right) Upper back Elbow ( Left Right) Knee ( Left Right) Mid back Wrist ( Left Right) Ribs Hand ( Left Right) Ankle ( Left Right) Chest Fingers (o Left Right) Foot ( Left Right) Abdomen Buttock ( Left Right) Toes ( Left Right) IN WHAT AREAS DID YOU EXPERIENCE LACERATIONS (CUTS)? Head Shoulder ( Left Right) Hip ( Left Right) Upper back Elbow ( Left Right) Mid back Wrist ( Left Right) Ribs Hand ( Left Right) Chest Fingers ( Left Right) Abdomen Buttock ( Left Right) Knee ( Left Right) Ankle ( Left Right) Foot ( Left Right) Toes ( Left Right) AT THE HOSPITAL. WHAT AREAS WERE X-RAYED? Head Shoulder OD Left Right) Hip (o Left Right) Upper back Elbow ( Left Right) Mid back Wrist ( Left o Right) Knee ( Left Right) Ribs Hand ( Left Right) Ankle ( Left Right) Chest Fingers ( Left Right) Foot ( Left Right) Abdomen Buttock ( Left Right) Toes ( Left Right)

5 WHERE DID YOU EXPERIENCE PAIN ON THE DAY FOLLOWING THE ACCIDENT? Head Neck Shoulder ( Left Right) Ann ( Left Right) Hip (0 Left o Right) Thigh ( Left Right) Upper back Elbow ( Left Right) Knee ( Left Right) Mid back Ribs Chest Abdomen Low back Wrist ( Left Right) Hand ( Left Right) Fingers ( Left Right) Buttock (o Left Right) Pelvis Ankle ( Left Right) Foot ( Left Right) Toes ( Left Right) SIGNATURE:

Auto Accident Injury Questionnaire

Auto Accident Injury Questionnaire MR# Name: Date of visit: Date of Accident: Is litigation pending? Yes No At the time of the accident did you experience any loss of consciousness? Yes No No, but I was