Skip to content

Search

Close

Search

Close

Home
About
Services
Forms
Products
Blog
Contact
Search for:
$0.00
0

Menu

Home
About
Services
Forms
Products
Blog
Contact
Search for:
$0.00
0

Search

Close

Our Services
Privacy
Site Map

Menu

Our Services
Privacy
Site Map

Request Appointment

Forms

Vehicle Accident Detail

Welcome to the healthcare management group inc.! In order to serve you better, please take a moment to complete this form, if you require assistance, please call or email the office.

Vehicle Accident detail form

Patients Information ( please complete all of the fields below )

Patient Information

Layout

First Name

Last Name

Layout (copy)

Date Of Accident

Time Of Accident

AM
PM

Please Describe The Accident /Injury In Your Own Words

Layout

Were You A

driver
front passenger
rear passenger
pedestrian

How Many People Were In The Accident Vehicle?

Accident Site

Road / Street Name

City / State

Nearest Insection With Road/ Street

Layout (copy)

Layout (copy) (copy)

Driving Conditions

Dry
Wet
Icy
Area

Layout

Which Direction Were You Headed?

Speed You Were Travelling?

Layout (copy)

Vehicle

Layout (copy) (copy)

Make & Model Of Vehicle You Were In

Were You Wearing A Seat Belt?

Yes
No

If Yes, What Type?

Lap
Shoulder

Layout (copy) (copy) (copy)

Was Vehicle Equipped With Airbags?

Yes
No

If Yes, Did It / They Inflate Properly?

Yes
No

did your seat have a headrest?

Did Your Seat Have A Headrest?

Yes
No

If Yes, What Was The Position Of The Headrest?

low
midposition
high

Impact

Layout

Did Your Car Impact Another Vehicle?

Yes
No

Did Your Car Impact A Structure?

Yes
No

If Yes, Explain

Layout

Did Any Part Of Your Body Strike Anything In The Vehicle?

Yes
No

If Yes, Explain

Layout (copy)

Was Impact From

Front
Rear
Left
Right
Other

At The Time Of Impact Were You:

looking straight ahead
looking to the right
looking to the left
looking down
looking up

Layout

Were Your Both Hands On The Steering Wheel?

Yes
No

If No, Which Hand Was On The Wheel?

Right
Left

Layout (copy)

Was Your Foot On The Brake?

Yes
No

If Yes, Which Foot Was On The Brake?

Right
Left

Were You?

surprised by impact
braced for impact

Other Vehicle

Layout

Make & Model Of Other Vehicle

Speed Other Vehicle Was Travelling

Which Direction Other Vehicle Headed?

Layout (copy)

Police

Layout (copy) (copy)

Did Police Come To The Accident Site?

Yes
No

Were There Any Witnesses

Yes
No

Layout (copy) (copy) (copy)

Was Police Report Filed?

Yes
No

Was A Traffic Violation Issues?

Yes
No

If Yes, To Whom

Patient Condition

Layout (copy) (copy) (copy) (copy)

Were You Unconscious Immediately After The Accident?

Yes
No

If Yes, For How Long?

Please Describe How You Felt Immediately After The Accident

Treatment

Layout

Did You Go To The Hospital?

Yes
No

When Did You Go?

immediately after accidet
next day
2 days or more after the accident

Layout (copy)

How Did You Go To The Hospital?

ambulance
private transportation

Name Of Hospital

Name Of Doctor

Diagnosis

Treatment Received

X-Rays Taken

Symptoms / Injuries

Layout

Have You Been Able To Work Since This Injury?

Yes
No

How Many Days Have You Missed?

Prior To The Injury Were You Able To Work On Equal Basis With Others Your Age?

Yes
No

If You Have Any Of The Following Symptoms Since Your Injury, Please Check :

arm / shoulder pain
back pain
back stiffness
chest pain
dizziness
ear buzzing
ear ringing
fatigue
feet / toe numbness
hand / finger numbness
headaches
irritability
jaw problems
leg pain
memory loss
nausea
neck pain
neck stiff
shortness of breath
sleep dificulty
stomach upset
tension
vision blurred

Is This Condition Getting Progressively Worse?

Yes
No
Unknown

Rate The Intensity Of Your Pain On A Scale From 1 ( Least Pain ) To 10 ( Severe Pain )

rate the secerity o your pain on a scale from 1 ( least pain ) to 10 ( severe pain ) (copy)

Mark An X On The Picture Where You Continue To Have Pain, Numbness Or Tingling.

Type Of Pain (copy)

sharp
dull
throbbing
numbness
aching
shooting
burning
tingling
cramps
stiffness
swelling
other

Layout (copy)

How Often Do You Have This Pain?

Is It Constant Or Does It Come & Go?

Does It Interfere With Your

work
sleep
daily routine
recreation

Activities Or Movements That Are Painful To Perform

sitting
walking
standing
walking
lying down

I verify that the above information is correct to the best of my knowledge.

Layout

Patient's Signature

Date

HCMG

Contact Us
Follow Us

Address: 303-330 HWY 7 East, Richmond Hill, ON L4B 3P8
Telephone: 905-882-1006 | 905-882-1007
E-mail: admin@hcmg.ca

Facebook Instagram Youtube Pinterest

0

Your Cart

Your cart is emptyReturn to Shop

To find out your shipping cost , Please proceed to checkout.

Continue Shopping

Scroll to Top

Forms

Vehicle Accident Detail

Patients Information ( please complete all of the fields below )

Patient Information

Accident Site

Vehicle

Impact

Other Vehicle

Police

Patient Condition

Treatment

Symptoms / Injuries

Mark An X On The Picture Where You Continue To Have Pain, Numbness Or Tingling.

I verify that the above information is correct to the best of my knowledge.

HCMG

All rights reserved. HCMG 2024