If your injury is NOT due to an automobile collision, please skip to the section titled “Areas of Complaint” UPON IMPACT (Please Answer the option that applies) :
Was your body straight in your seat?
If no, turned to the?
Were you aware that you were about to be hit?
Were you wearing a seatbelt at the time of the accident?
Did your chest / head hit the steering wheel?
Did an airbag deploy?
Did your head hit the Windshield?
Did your knees hit the dashboard?
Did the seat break?
On a scale of 1-10, please rate your pain level.
Are you experiencing any of the following since your injury? (Check all that apply)
List all the doctors that you have seen as a result of your injuries:
Please list all past surgeries, major illnesses or diseases, hospitalizations (with approximate date)
Please list any previous accidents and injuries: