Automobile accident history form
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| AUTOMOBILE ACCIDENT HISTORY FORM
Name:____________________________________________ Today’s Date:__________ Date of Accident______________________________ Time of Accident ____________ City of Accident:______________________________ Street of Accident____________ Road Conditions at the time of the accident: WET DRY ICY OTHER______________ Did the police come to the accident scene? YES NO; Is there a report? YES NO Where did your car get hit (side impact: i.e. drivers/passenger side, head on , or rear ended Ect.)?___________________________________________________________________ Did you go to the hospital? YES NO If yes, what is the name and city of the hospital? ________________________________ How did you get to the hospital? ___________________________________________ What parts of your body were x-rayed at the hospital? ____________________________ What did the hospital do for your injuries? _____________________________________ How long did you stay at the hospital? ________________________________________
What bruises did you sustain during this accident? _______________________________ Where were you seated in the vehicle? ________________________________________ Were you aware of the approaching collision prior to impact, of did the impact catch you by surprise? AWARE SURPRISE Did you lose consciousness (black out) upon impact? YES NO: How long _________ Did you experience a flash of light or explosion in your head? YES NO Did you become any of the following from the accident? (please circle) CONFUSED DISORIENTED LIGHT HEADED DIZZY NAUSEATED BLURRED VISION RING/BUZZ ON EARS If you still have any of those symptoms, which ones? ____________________________ Are you currently suffering from any of the following? (please circle) RESTLESSNESS IRRITABLE DIFFICULT CONCENTRATING FORGETFULLNESS SLEEPNESSNESS DIFFICULT WITH MEMORY REDUCED TOLERANCE TO HEAT REDUCED TOLERANCE TO ALCOHOL How far is the top of the headrest or seatback from the top of your head (approximately) ______________ inches above or below Were you wearing a seatbelt? YES NO If yes, was it a lap seatbelt __________ shoulder-lap seatbelt _________________ List the year, make and model of the vehicle you were in: Year___________ Make ____________ Model _____________________ Was your car stopped at the time of impact? YES NO If yes, was the driver’s foot also on the brake? YES NO If no, then estimate the speed of the vehicle you were in: __________mph
Gaining Speed? ___________ Traveling at a steady rate of speed? __________ On what part of the automobile did your following body parts hit? Head hit__________________________ Chest hit _______________________ Right/left shoulder hit________________ Right/left arm hit_________________ Right/left hip_______________________ Right/left leg hit__________________ Right/left knee hit___________________ Other___________________________ Did you receive any injury or bruise from the seatbelt? YES NO If YES, then describe:______________________________________________________ What is the estimated cost damage to the vehicle you were in?______________________ Was the trunk of your body pointed straight forward at the time of the collision? YES NO; If no, how was it turned? ________________________________ Was your head pointed straight forward? YES NO; If no, what direction was it turned and by how much?________________________________________________________ What is the year, make and model of the other vehicle? Year___________ Make _________________ Model____________________ Was the other vehicle moving at the time of the collision? YES NO If yes, what was the approximate speed? ____________mph If the other vehicle was moving at the time of the collision was it (please circle): Slowing Down Gaining Speed Traveling at a steady speed Please describe to the best of your knowledge, what happened during this accident __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Directory: clients clients -> Dr. Cevin C. Cormier (251) 343-9990 curriculum vitae personal clients -> Thales Establishes Presence at Mobile Airport Authority’s Brookley Mobile Aeroplex clients -> Lepto: Give to “at risk”puppies clients -> Dpa microphones Help Daniel Blinkhorn Capture Multi-Channel Eco-Acoustic Recordings clients -> Dpa microphones Bring New Meaning To The Phrase ‘In-Car Audio’ clients -> Rugged Computing Industry Discussion (1) Rugged Tablet pc company executives answer Ruggedpcreview's questions about opportunities in the rugged and semi-rugged tablet market as a result of the iPad's popularity clients -> Brinda mehta clients -> Phys Ther. 2012 May;92(5): 718-25. doi: 10. 2522/ptj. 20110261. Epub 2012 Jan 19 clients -> Icce-25 July 16-22, 2017 Rome, Italy keynotes Download 11.95 Kb. Share with your friends:
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