Motor Vehicle Injury History Form

Motor Vehicle Injury History
Time
:
Visibility at time of accident:
Road Conditions at time of accident:
Type of Accident:
Did you see the accident coming?
Did you brace for impact?
Were seatbelts worn?
Did the Airbag Deploy?
Was your car braking?
Was your car moving at the time of the accident?
mph
mph
Head/ Body position at the time of impact:
As a result of the accident you were:
Were you wearing a hat or glasses?
Could you move all parts of your body?
Were you able to get out of the car and walk unaided?
Did you get any bleeding cuts?
Did you get any bruises?

Please describe how you felt:

Check ALL symptoms that you have notice since the accident:

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