Crossman Chiropractic

Auto Accident Questionnaire

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Name
Date of Accident

THE FOLLOWING QUESTIONS PERTAIN TO YOU AND THE VEHICLE YOU WERE IN:

Vehicle Type
Vehicle Size
YOUR POSITION IN THE VEHICLE
SPEED OF YOUR VEHICLE
WHY WAS YOUR VEHICLE STOPPED?
COLLISION TYPE

THE FOLLOWING QUESTIONS CONCERN THE OTHER VEHICLE INVOLVED IN THE ACCIDENT:

Vehicle Type
Vehicle Size

CONDITIONS AT THE TIME OF THE ACCIDENT:.

Time of Day
Road Conditions
Visibility
Visibility Compromised By:

THE FOLLOWING QUESTIONS CONCERN THE MOMENT OF IMPACT OF THE ACCIDENT:

Were You
Restraints: (check all that apply)
If you were the driver of the vehicle, was your foot on the brake pedal?
Was the air bag deployed?
What position was the head rest in?
What was the position of your head at the time of impact?
Was your head thrown....?
What position was your body at the time of impact?
Was your body thrown...?
What was the damage to the vehicle YOU were in?
Citations?

AS A RESULT OF THE FORCE OF THE COLLISION, WHICH OBJECTS IN THE VEHICLE DID YOUR BODY STRIKE?

Head
Left arm
Right arm
Torso
Left leg
Right leg

THE FOLLOWING QUESTIONS CONCERN THE TIME PERIOD IMMEDIATELY FOLLOWING THE ACCIDENT:

Did you loose consciousness?
Immediately following the accident, did you feel...?
Were you able to walk unaided?
Where did you go after the accident?
Next day discomfort?
Did your major complaints exist before the accident?
In what areas did you IMMEDIATELY feel pain?
In what areas did you experience lacerations (cuts)?
At the hospital, what areas were x-rayed?
Where did you experience pain on the day FOLLOWING the accident?