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Your Full Name *
Today's Date
Did the accident occur while at work? ("Yes" or "No")
When did the auto accident happen?
What time of day did the accident happen and where? (State & Road or Intersection)
Year / Make / Model of vehicle YOU were in?
(If collision with another vehicle) The other vehicle's type?
Were you the driver? ("Yes" or "No")
If you were NOT the driver, Where were you sitting as passenger?
Were you wearing a seatbelt? ("Yes" or "No")
Did your airbags deploy? ("Yes" or "No")
What were the road conditions? (wet, dry, icy, gravel, pavement)
Side, front, or rear impact?
Was your vehicle stopped or moving at the moment of impact?
Was you vehicle drivable after the accident? ("Yes" or "No")
Did you brace yourself? ("Yes" or "No")
How many vehicles were in the collision?
How did you feel immediately following the collision?
How did you feel hours or days later?
Were you knocked unconscious? ("Yes" or "No")
Did you go to the emergency room? ("Yes" or "No")
If you DID go to the emergency room, what was done?
Have you had any treatments before coming to our office today? ("Yes" or "No")
If YES, you have had treatments, what kind of treatments? And how did those treatments help?
Have you had an auto accident in the past? ("Yes" or "No")
If you have had an auto accident in the past, what areas of the body were injured?
What symptoms were you having before this collision?
Have you retained an attorney? ("Yes" or "No")
If you HAVE retained an attorney, what is the name and address of your attorney?
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