Motor Vehicle Injury History Form Motor Vehicle Injury History Last Name * First Name * Date * Insurance Company Claim Number Adjuster’s Name Insurance Phone # Date of Accident * Time 121234567891011 : 00153045 AMPM Driver of Car Where were you seated? Visibility at time of accident: * Poor Fair Good OtherOther Road Conditions at time of accident: Icy Rainy Wet Clear Dark OtherOther Where was your car struck? * Type of Accident: Head-on Collision Broad-side Collision Front Impact Rear-end car in front Rear Impact Non- collision At the time of the accident, recall what parts of your head or body hit what parts on the inside of your car: Did you see the accident coming? * Yes No Did you brace for impact? Yes No Were seatbelts worn? * Yes No Did the Airbag Deploy? Yes No Was your car braking? * Yes No Was your car moving at the time of the accident? * Yes No How fast would you estimate you were going? * mph How fast would you estimate the other car was going? * mph Head/ Body position at the time of impact: * Head turned left/right Body straight in sitting position Head looking back Body rotated right/left Head straight forward OtherOther As a result of the accident you were: * Rendered unconscious In shock Dazed, Circumstances Vague OtherOther Were you wearing a hat or glasses? * Yes No Could you move all parts of your body? * Yes No What parts couldn’t you move and why? * Were you able to get out of the car and walk unaided? * Yes No Why not? * Did you get any bleeding cuts? * Yes No Where? * Did you get any bruises? * Yes No Where? * Please describe how you felt: Immediately after the accident: * Later that day: * The next day: * Check ALL symptoms that you have notice since the accident: * Headache Neck Pain/ Stiffness Mid Back Pain Eyes Light Sensitive Pain Behind Eyes Dizziness Fainting Sleeping Problems Numbness in Fingers Numbness in Toes Loss of Smell Loss of Taste Loss of Memory Fatigue Breath Shortness Irritability Depression Ringing/ Buzzing Loss of Balance Tension Cold Hands Cold Feet Diarrhea Constipation Chest Pain Nervousness Cold Sweats Anxious Driving Facial Pain Clicking or Popping Jaw Low Back Pain OtherOther If you are human, leave this field blank. Submit Δ
