Skip to content
(610) 459-4114
statelinechirocenter@gmail.com
Facebook
X-twitter
Instagram
Home
Services
Spinal Decompression
Deep Tissue Laser Therapy
LaserSkin Med Spa
Mechanical Traction
Joint Rehabilitation
Science Based Nutrition
Physiotherapy
Shockwave Therapy
Patients
About Us
Blog
Contact
Menu
Home
Services
Spinal Decompression
Deep Tissue Laser Therapy
LaserSkin Med Spa
Mechanical Traction
Joint Rehabilitation
Science Based Nutrition
Physiotherapy
Shockwave Therapy
Patients
About Us
Blog
Contact
Call Now
Motor Vehicle Injury History Form
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
12
1
2
3
4
5
6
7
8
9
10
11
:
00
15
30
45
AM
PM
Driver of Car
Where were you seated?
Visibility at time of accident:
*
Poor
Fair
Good
Other
Other
Road Conditions at time of accident:
Icy
Rainy
Wet
Clear
Dark
Other
Other
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
Other
Other
As a result of the accident you were:
*
Rendered unconscious
In shock
Dazed, Circumstances Vague
Other
Other
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
Other
Other
If you are human, leave this field blank.
Submit
Δ
