Auto Accident

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Auto Accident

Welcome to Corrective Chiropractic. Thank you for taking a moment to fill in our Auto Accident Form. Please fill this form completely and to the best of your knowledge. When complete you will submit this HIPAA compliant form. Let us know if you have any questions. 252-758-7583

Email *

First Name *

Last Name *

Date of Accident *

YYYY

Time of Accident *

Time

What did your vehicle impact? *

A Vehicle

Other:

Were you the *

Driver

Front Passenger

Rear Passenger

Vehicle Make *

Vehicle Model *

Vehicle Year *

Street/Location *

# of Persons in Your Vehicle *

Were you *

proceeding along

accelerating

stopped in traffic

stopped at light

stopped at intersection or stop sign

making a right turn

making a left turn

slowing down

parking

Speed of your vehicle *

Speed of their vehicle *

Impact to your vehicle came from? *

Front

Rear

Right

Left

Other:

How was visibility at the time of the collision? *

Poor

Fair

Good

What were the road conditions? *

clean and dry

wet

icy

Did you *

anticipated the collision

did not anticipate the collision

Were you wearing a seat belt? *

Yes

Did you have any bruising from the seat belt? *

Yes

Were you *

braced for the impact

was not braced for the impact

What was your hand position during the crash? *

both hands on the steering wheel

the right hand on the steering wheel

the left hand on the steering wheel

no hands on the steering wheel

In relation to the base of your skull, where was the headrest? *

Above

Below

At The Base

The direction you were facing *

facing straight forward

head and/or body turned to the left

head and/or body turned to the right

head looking down

head looking up

Were you rendered unconscious? *

Yes

If Yes, How Long?

Did the vehicle have airbags? *

Yes

Did the airbags inflate? *

Yes

Did any part of your seat break? *

Yes

Did your body strike anything in the vehicle? *

Yes

Have you worked since this injury? *

Yes

Are your work activities restricted? *

Yes

Were there any witnesses? *

Yes

Visited a Hospital or Doctor? *

Yes

Name of hospital:

When did you go to the hospital?

Immediately

Next Day

2 Days Plus

Clear selection

How did you get to the hospital?

Ambulance

Private transportation

Clear selection

Was the Doctor a?

D.C.

M.D.

D.O.

D.D.S.

Clear selection

Were any X-rays taken? *

Yes

Medication prescribed? *

Yes

Please Choose ALL Treatment You have done since your Accident. *

Home treatment with heat

Home treatment with cold

Home treatment with over the counter medication

Home treatment with rest

Physical Therapy

Chiropractic Treament

Acupuncture

Neurologist

Massage

No treatment since accident

Required

Did the police arrive? *

Yes

Police report filed? *

Yes

Traffic violation issued? *

Yes

If Yes, To Whom? *

Driver of Car I was in

Other Driver

Other:

Vehicle was

towed from the scene of the crash

driven away after the crash

Clear selection

Retained an attorney? *

Yes

If Yes, Name & Phone#

If Yes, Please Explain

Describe the accident? *

How did you feel right after? *

Names of all persons in this accident: *

Have you contacted Your auto insurance company? *

Yes

Claim # for Medical Care (your insurance) *

Your Insurance Contact Person *

Insurance Phone *

Have you contacted The Other Driver's auto insurance company? *

Yes

Claim # (liable party) *

Insurance Contact Person *

Insurance Phone *

Other Vehicle Make/Model *

Clear form

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