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Submit Your Accident Report Form To Us

To better serve you, please share with us all details related to your most recent auto accident. This is a 5 part questionnaire that should take no more than a few minutes to complete. Please allow a few seconds for the form to load & activate as you navigate through each section before inputting your information in the data fields.

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

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Our goal is to not only alleviate pain, but more importantly, inspire and educate our patients to become active participants in their own well being.

Visit Us

Fort Myers Clinic
1791 Boy Scout Dr., Ste 6
Fort Myers, FL 33907

Phone: (239) 332 - 2555
Fax: (239) 332 - 2556

Need To Report An Accident?

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