VEHICLE ACCIDENT INFORMATION

PATIENT INFORMATION

Date

Patient Name

Date of Accident	Time of Accident

Please describe the accident in your own words:

Were you the:	Driver	Front Passenger	Rear Passenger	Pedestrian

How many people were in the accident vehicle?

ACCIDENT SITE

Road/Street Name

City/State

Nearest intersection with road/street

Driving Conditions Dry	Wet	Icy Other

Which direction were you headed?

Speed you were traveling

VEHICLE

Make and model of vehicle you were in:

Were you wearing a seatbelt?	Yes	No

If yes, what type?	Lap	Shoulder

Was vehicle equipped with airbags? Yes	No

If yes, did it/they inflate properly?	Yes	No

Did your seat have a headrest?	Yes	No

If yes, what was the position of the headrest?

Low	Midposition	High

OTHER VEHICLE

(if applicable)

Make and model of other vehicle

Which direction was the other vehicle headed?

Speed other vehicle was traveling

IMPACT

Did your car impact another vehicle?	Yes	No

Did your car impact a structure?	Yes	No

If yes, explain

Did any part of your body strike anything in the vehicle?

Yes	No	if yes, explain

Was impact from :

Front	Rear	Left	Right	Other

At the time of impact were you:

Looking straight ahead	Looking to the right

Looking to the left	Looking down

Looking up

Were both hands on the steering wheel? Yes	No

If no, which hand was on the wheel?	Right	Left

Was your foot on the brake?

If yes, which foot was on the brake?	Right	Left

Were you: Surprised by impact	Braced for impact

POLICE

Did the police come to the accident site? Yes	No

Were there any witnesses?	Yes	No

Was a police report filed?	Yes	No

Was a traffic violation issued?

If yes, to whom?	________