Structural Healing Brandi McLaughlin
971.570.3456
AUTOMOBILE ACCIDENT FORM
Patient Name: _____________________________________________________ Please com plete the fo rm ca refully, c he ck in g o r w rit in g you r a nswe rs as need ed: Date of Accident? Road conditions were: _______________ Wet Dry Yes Icy No Time of Accident: _______________ AM PM Where did the accident occur: City: ________________ Did the police come to the scene? Street: ___________________________________________ Other: __________________________________________ Date: _____________________
Please describe to the best of your ability what happened during this accident: ____________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
The following questions pertain to you (the patient) and the vehicle you were traveling in:
Year: __________ Were you driving? Make: ____________ Model: ____________________ Yes No Yes Yes Yes Yes Yes Gaining speed No No No No No mph. Slowing down Looking back ( Left Right) If yes, for how long? __________________________ If yes, was there a shoulder strap? ________________ of the car you were in. If no, where were you in the car: __________________________________________
Were you aware of the approaching collision? Did you lose consciousness upon impact? Were you wearing your seatbelt? Was your car stopped at the time of impact? If yes, was the driver’s foot on the break? If the car was moving, how fast were you going? Were you moving at a: Head turned right Head turned left Steady speed What was your body position at the time of impact: Head straight
Body in straight position
Other: ____________________________________ Left/Right hip: ____________________________________ Left/Right leg: ____________________________________ Left/Right knee: No No
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On what part of the car did the following body parts hit (if any): Head: _______________________________________ Chest: ______________________________________ Left/Right shoulder: ___________________________ Left/Right arm: _______________________________ Did you get bleeding cuts from this accident? Did you get any bruises from this accident? Were you taken to the hospital?
Auto_Acc_Form.doc Updated: 3-Feb-08
__________________________________
Other: __________________________________________
Yes Yes No
Yes
If yes, how did you get there? ______________________________
Structural Healing Brandi McLaughlin
971.570.3456
Were X-Rays takend?
Yes
No
If yes, what areas were X-Rayed? ____________________________ Irritability Buzzing in ears Loss of smell Chest pain Loss of balance Loss of taste Cold sweats Constipation Hands cold Stomach upset Jaw pain Feet cold
Check symptoms you have noticed si nce the accident: Headaches Mid back pain Dizziness Numbness in fingers Fever Face flushed Neck pain Low back pain Head feels heavy Numbness in toes Fatigue Depression Neck stiffness Nervousness Pins & needles in arms Shortness of breath Loss of memory Diarrhea Sleeping problems Tension Pins & needles in legs Light bothers eyes Ears ring Fainting
Please list any of the above symptoms that you had before this accident (if any), ___________________________________ _________________________________________________________________________________________________ Have you been under a doctor’s care as a result of this accident? Have you lost any days from work? If yes, dates absent from work: From Yes to Date returned to normal work: _______________ No Yes No Phone #: ________________________ If yes, please list the doctor’s name: _________________________________
List any dates of limited work activities: ________________________
The following questions pertain to the other vehicle involved in the accident:
Year: __________ Make: ____________ Model: ____________________ Yes No Slowing down mph. Gaining speed of the other car. Was the other car moving at the time of impact? If yes, the estimated speed: Were they moving at a: Steady speed
The following questions pertain to both parties auto insurance information:
Please provide the following information on your auto insurance (if you were in your own car). If you were driving or a passenger in another’s vehicle give their auto insurance information: Company name: _________________________________ Adjuster’s name: ________________________ Insured’s name: _________________________________ Policy #: ________________ Phone #: ___________________
Please provide the information on the auto insurance of the other party’s vehicle : Company name: _________________________________ Adjuster’s name: ________________________ Insured’s name: _________________________________ Policy #: ________________ Phone #: ___________________
Patient Signature: _______________________________________
Auto_Acc_Form.doc Updated: 3-Feb-08
Date: ________________________
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