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239-332-2555
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Jason B. Kaster, DC
Thuong Nguyen, LMT
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Accident Report Form
Location
Contact
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Automobile Accident Description
Step 1 of 5
20%
Full Name
Phone Number
*
Email
Your vehicle type
*
Car
Station Wagon
Van
Pickup Truck
Large Truck
Bus
Other
Your position in vehicle
*
Driver
Front Passenger
Left Rear Passenger
Right Rear Passenger
Other
Other
What was your vehicle doing at the time of the accident?
*
Stopped at intersection
Stopped in traffic
Stopped at light
Making a right turn
Making a left turn
Parking
Proceeding along
Slowing down
Accelerating
Other
Other
Time / Speed / Damage
Date of accident
*
Time of accident (am/pm)
*
Your vehicle's speed
*
Their vehicle's speed
*
Damage to your vehicle
*
Mild
Moderate
Totaled
Details of Accident
Visibility at time of accident
*
Poor
Fair
Good
Who hit who/what?
*
You hit other vehicle
Other vehicle hit you
Other
You hit...(object)
Road Conditions
Road conditions at time of accident
*
Icy
Wet
Sandy
Dark
Clean and dry
Point of impact
*
Head-on
Rear-end
Left front
Left rear
Right front
Right rear
Body Position
Did you see the accident coming?
*
Yes
No
Were you braced for the impact?
*
Yes
No
Did you have a seat belt on?
*
Yes
No
Did you have a shoulder harness on?
*
Yes
No
Does your vehicle have headrests?
*
Yes
No
What was the position of your headrest at the time of the impact?
*
Even with top of head
Even with bottom of head
Middle of neck
What was the direction of your head at the time of the impact?
*
Facing straight forward
Turned to the right
Turned to the left
Did driver side air bags deploy?
*
Yes
No
Did passenger side airbags deploy?
*
Yes
No
Did side airbags deploy?
*
Yes
No
In the case of a motor vehicle accident, enter any additional information here that is not covered by the above questions.
During the Accident
Did your body strike the inside of your vehicle?
*
Yes
No
If yes, describe
Did you lose consciousness during the injury?
*
Yes
No
If yes, do you know for how long?
Your vehicles estimated damage?
*
Did police show up at the scene?
*
Yes
No
Was an accident report filled out?
*
Yes
No
After the accident
Check off your symptoms right after and a few days following the accident.
Headache
Neck pain
Neck stiffness
Fainting
Ringing in ears
Loss of smell
Pain behind eyes
Dizziness
Nausea
Confusion
Fatigue
Tension
Irritability
Mid back pain
Low back pain
Nervousness
Loss of taste
Toe numbness
Constipation
Cold hands
Cold feet
Diarrhea
Depression
Anxiety
Chest pain
Pain behind eyes
Shortness of breath
Sleeping problems
Others not listed above
Where did you go after the accident?
*
Home
Work
Hospital ER
Private Doctor
How did you get there?
*
Drove self
Somebody else
Ambulance
Police
Were x-rays done?
*
Yes
No
Body parts x-rayed?
X-rays revealed?
Was lab work done?
*
Yes
No
What lab work?
Treatments
*
Cervical Collar
Ice
Other
Other treatments
Medications
*
Follow-up instructions
*
Treatment History
Fill in any other doctor(s) seen prior to your first visit to this office
Doctors name
Doctors area of specialty
First visit date
X-rays done?
Yes
No
Types of treatments received
Number of treatments received
Currently treating?
Yes
No
Did treatments benefit you?
Yes
No
Last visit date
