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Accident Form
Vehicle Accident Form
Welcome to the healthcare management goup inc.! In order to serve ypu better, please take a moment to complete this form, if you require assistance, please call or email the office.
Accident detail form
Patients Information ( please complete all of the fields below )
Vehicle Accident Form
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Patient Information
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first name
Last name
Layout (copy)
date of accident
time of accident
AM
PM
please describe the accident /injury in your own words
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were you a
driver
front passenger
rear passenger
pedestrian
how many people were in the accident vehicle?
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road / street name
city / state
Layout (copy)
nearest insection with road/ street
Layout (copy) (copy)
driving conditions
Dry
Wet
Icy
Area
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which direction were you headed?
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speed you were trvelling?
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 peoperly?
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
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did your car impact another vehicle?
Yes
No
did your car impact a structure?
Yes
No
if yes, explain
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did any part of your body strik anything in the vehicle?
Yes
No
if yes, explain
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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 ahnds on the steering wheel?
Yes
No
if no, which hand was ont he wheel?
Right
Left
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was your foot on the brake?
Yes
No
if yes, which foor was ont the brake?
Right
Left
were you?
surprised by impact
braced for impact
other vehicle
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make & model of other vehicle
speed other vehicle was travelling
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which direction other vehicle headed?
Police
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did police come to the accident site?
Yes
No
were there any witnesses
Yes
No
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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 ling?
please describe how you felt immediately after the accident
treatment
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did you go to the hospital?
Yes
No
when did you go?
immediately after accidet
next day
2 days or more after the accident
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how did you go to the hospital?
ambulance
private transportation
name of hospital
name of doctor
diagnosis
tratment recieved
x-rays taken
symptoms / injuries
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have you been able to work since this injury?
Yes
No
how many days have you missed?
prior to the injury were you able yo work on equal basis with others your age?
Yes
No
if you have any of the following symptons 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 secerity o 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 )
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.
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type of pain
sharp
dull
throbbing
numbness
aching
shooting
burning
tingling
cramps
stiffness
swelling
other
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how often do you have this pain?
is ti 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
patients sigmature
date
Submit
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