Pre-Existing Contitions
Have you sought care for a health problem in the past year? No Yes Past 2 years? No Yes
If yes, what condition?
Do you take medication? No Yes Describe
Accident History
Date of Accident
Brief description of accident
List any parts of your body that made contact with vehicle parts
Were seatbelts worn? No Yes Shoulder Lap
List seat position in vehicle
If the vehicle had headrests, describe the position compared to your head:
Top of headrest aligned with top of head
Top of headrest aligned with middle of head
Top of headrest aligned with bottom of head
Briefly describe the impact collision:
Head on collision Lift side impact Right side impact Rear end collision
Were you braced for the impact? No Yes Was your car stopped? No Yes
Were you looking in the rear view mirror? No Yes Were your brakes applied? No Yes
Any previous motor vehicle accidents? No Yes Describe
Was treatment administered: No Yes Describe
Type of Accident: Auto Workers Compensation Fall Other
Auto Accident
If yes, was treatment rendered previously? No Yes Describe
