IF YOURS IS AN ACCIDENTAL INJURY PLEASE COMPLETE THE FOLLOWING QUESTIONS
Date of Accident: ___________________
Hour ________
AM _________ PM
Location __________________
How did Accident Occur?
Auto Collision
On-the-job Injury
Other ________________________
If not an auto collision, please describe the circumstances: _______________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Did you report the injury to your foreman or employer?
YES
NO
NO
Did he (they) recommend care at our office?
YES
If auto accident, were you
Driver
Passenger
Pedestrian
If auto collision, were you struck from
Behind
Right Side
Left Side
Front
Auto was Parked
Did your car strike the other(s) involved?
YES
NO
Undetermined
Undetermined
OR did the other car strike yours?
YES
NO
As a result of the accident, were traffic citations issued to you?
YES
NO
To the driver of the other car?
YES
NO
YES
NO
To the driver of your car?
List the extent of the injuries as you know them ______________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
YES
NO
Did you require post-accident hospitalization?
Check symptoms you have noticed since accident:
Dizziness
Light Bothers Eyes
Diarrhea
Headache
Head Seems Too Heavy
Loss of Memory
Feet Cold
Neck Pain
Pins and Needles in Arms
Ears Ring
Hands Cold
Neck Stiffness
Pins and Needles in Legs
Face Flushed
Stomach Upset
Problems Sleeping
Numbness in Fingers
Buzzing in Ears
Constipation
Back Pain
Numbness in Toes
Loss of Balance
Cold Sweats
Nervousness
Shortness of Breath
Fainting
Fever
Tension
Irritability
Fatigue
Loss of Smell
______________________
Chest Pain
Depression
Loss of Taste
______________________
Symptoms other than above ____________________________________________________________________
Have you lost any days of work?
YES
NO
Dates: _________________________________________
Insurance Companies involved:
My Company ___________________________________________________________________________
Company of person responsible for injuries? ____________________________________________________
YES
NO
Have you been contacted by an insurance adjuster or company representative regarding this claim?
Do you have an attorney that has advised you in this case?
YES
NO
Attorney's Name ___________________________________________________________________________
Address _____________________________________________________
Telephone _________________