Auto Accident and Work Injury Forms

Name *

Date of Accident *

Time

Where did it happen? *

Describe the accident in your own words:

Where you the *

driver
passenger?

If passenger, were you sitting in *

front
rear right
rear left

Did your vehicle strike another vehicle? *

Yes
No

Was your vehicle struck by another? *

Yes
No

Was the impact from the: *

front?
the rear?
the right side?
The left side?

At the time of the impact were you looking: *

forward?
to the left?
to the right?

Were both hands on the steering wheel? *

Yes
No

Was your foot on the brake? *

Yes
No

Were you braced for the impact? *

Yes
No

Were you wearing a seat belt? *

Yes
No

Did you strike anything in the vehicle? *

Yes
No

If yes, what:

Immediately after the accident, how did you feel? *

Were you unconscious? *

Yes
No

Were you in a daze? *

Yes
No

Did you go the hospital? *

Yes
No

If yes, when did you go to the hospital?

How did you get to the hospital?

Name of hospital? *

Did they take X-Rays/MRIs? *

Yes
No

Which:

What did they diagnose you with?

What treatment did they do?

Did they admit you overnight? *

Yes
No

If yes, for how long:

What other recommendations were made?

Did you see any other doctors? *

Yes
No

If yes, which:

Have you lost any time from work for this accident? *

Yes
No

If yes, what dates have you lost?

From

To

Partially Disabled?

Yes
No

Fully Disabled?

Yes
No

YDESCRIBESYOURCOND

For use with Neck and/or Back Problems only

)In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities. For each item below, please circle the number which most closely describes your condition right now

Personal Care(washing, dressing, etc.) *

0 - No Pain, No Restrictions
1 - Mild Pain, No Restrictions
2 - Moderate Pain, need to go slowly
3 - Moderate Pain, need some assistance
4 - Severe pain, need 100% assistance

Travel(driving, etc.) *

Work *

0 - can we do usual work plus unlimited extra work
1 - can do usual work, no extra work
2 - can do 50% of usual work
3 - can do 25% of usual work
4 - cannot work

Frequency of pain

0 - No pain
1 - Occasional pain, 20% of the day
2 - Intermittent pain, 50% of the day
3 - Frequent pain, 75% of the day
4 - Constant pain, 100% of the day

Lifting *

0 - No pain with heavy weight
1 - Increased pain with heavy weight
2 - Increased pain with moderate weight
3 - Increased pain with light weight
4 - Increased pain with any weight

Walking *

0 - No pain, any distance
1 - Increased pain after 1 mile
2 - Increased pain after 1/2 mile
3 - Increased pain after 1/4 mile
4 - Increased pain with all walking

Standing *

0 - No pain after several hours
1 - Increased pain after several hours
2 - Increased pain after 1 hour
3 - Increased pain after 1/2 hour
4 - Increased pain with any standing

Total Score *

Name *

Date / Time *