ACCIDENT/INJURY QUESTIONNAIRE
Name
*
First Name
Middle Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
AUTOMOBILE ACCIDENT
AUTOMOBILE ACCIDENT
Additional Information
Was anyone else in the vehicle with you?
No
Yes
Number of people
You were?
Front Seat (Driver/Passenger)
Rear Seat (Behind Driver, Middle, Behind Passenger, 2nd Row, 3rd Row)
Name of Driver
if not self
Name of Driver of other vehicle
Did airbags deploy?
No
Yes
Did Police arrive?
No
Yes
Using Seatbelt?
No
Yes
Did you strike the windshield or object in car?
No
Yes
Describe
Were you knocked unconscious?
No
Yes
How long?
Where was your vehicle impacted?
Front
Rear
Passenger Side
Driver's Side
Other
Where was the other vehicle impacted?
Front
Rear
Passenger Side
Driver's Side
Other
Your Auto Insurance
Policy #
Claim #
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Other's Auto Insurance
Policy #
Claim #
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
WORKER’S COMPENSATION INJURY
WORKER’S COMPENSATION INJURY
Additional Information
Employer
Occupation
Claim #
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Contact Person
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
GENERAL ACCIDENT/INJURY INFORMATION
GENERAL ACCIDENT/INJURY INFORMATION
Date of Accident
-
Month
-
Day
Year
Date
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Please describe the accident in as much detail as possible
Before the accident/injury:
Have you ever had any complaints in the involved area before?
No
Yes
If yes - Were they present at the time of the accident/injury?
No
Yes
If yes — Summarize these complaints prior to the accident:
Were you capable of performing all of your work activities without restriction?
No
Yes
At the time of the accident/injury:
Did you feel pain immediately after the accident?
No
Yes
Later that day
Next day
Other
Were you taken anywhere after the accident?
No
Yes
Later that day
Next day
Other
If yes, How?
If yes, Where?
If yes, Did you receive treatment?
No
Yes
Describe
Since the accident/injury:
Are your symptoms:
Improving?
Getting Worse?
The Same?
Are your work activities restricted as a result of this accident/injury?
No
Yes
If yes — How?
Have you missed any work since this accident?
No
Yes
If Yes, dates?
Have you retained an Attorney?
No
Yes
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Patient Number
Skip if not known yet
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