Motor Vehicle Collision Questionnaire | Madeira Chiropractic Electronic Forms

This field is for validation purposes and should be left unchanged.

Name*

First Last

Email*

Enter Email Confirm Email

Date of Birth*

Month

Day

Year

Home Address*

Street Address Address Line 2 City State ZIP Code

Did this motor vehicle collision occur while you were working?*

Yes

Date of Collision:

MM slash DD slash YYYY

Time of Collision:

AM/PM

Location of Collision:

Where you the:

Did the airbags deploy?

Yes

Number of people in your vehicle:

Were you wearing a seatbelt?

Yes

Type of Collision:

Broadside

Frontal Impact

Hit a Stationary Object

Rear Impact

Other

In your own words, describe the accident:

Were you knocked unconscious?

Yes

How long were you unconscious?

Approximate speed of your vehicle:

Approximate speed of other vehicle:

Please describe the road conditions:

Dry

Icy

Snowy

Wet

How did you feel immediately after the collision?

How did you feel later the same day?

How did you feel the next day?

Were you taken to the hospital?

Yes

Was it by:

Name of the Hospital:

How long were you in the hospital?

What did they say was wrong with you?

What tests did they perform?

What type of treatment(s) did you receive for your condition?

Medication

Physical Therapy

Surgery

Other

Other doctors you have seen since the collision:

Is there an attorney involved?

Yes

Name of Attorney:

Since this collision, are your symptoms?

Improving

Getting Worse

Staying the Same

Unsure

Please check all that you are experiencing or have experienced since the collision:

Anxiousness

Arm Numbness/Tingling

Arm Pain

Depression

Dizziness

Fainting/Lightheadedness

Fatigue

Grating Noises in Neck

Head Seems Heavy

Headache(s)

Irritability

Lack of Energy

Leg Numbness/Tingling

Leg Pain

Lower Back Pain

Light Sensitivity

Loss of Balance

Loss of Memory

Mid Back Pain

Muscle Cramping

Muscular Tension/Stiffness

Neck Pain

Neck Stiffness

Pinched Nerve

Ringing in Ears

Shortness of Breath

Shoulder Blade Pain

Shoulder Pain

Sleeping Problems

Tight Chest

Upper Back Pain

Other

None of the Above

Are there any daily activities that you are unable to do because of this collision such as sleeping comfortably, driving or sitting for long periods, lifting, sexual activity, etc.?

Yes

Activities that are affected:

Auto Insurance Information

Did you report this accident to your insurance company?

Yes

Name of Your Auto Insurance Company:

Agent's Name:

Policy Holder's Name:

Policy #:

Claim # for this Accident:

Name of Claims Adjuster:

Phone # of Insurance Company:

Address Where to Send Claims:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country