Personal Injury Questionnaire Online Form First Name Last Name Age Birthday Gender Male Female Last 4 Digits of SS#: Driver's License # Email Mobile Phone Home Phone Address City State Zip Code Employer Occupation Work Phone Name of your Auto Insurance Company: Policy Number: Agents Name: Name on Policy (if other than self): Claim Number: Name of Adjuster: Adjuster's Phone Number: Other Driver's Insurance Company (At Fault) Other Driver's Policy Holder Name (At Fault): Other Driver's Claim Number (At Fault): Other Driver's Adjuster (At Fault): Other Driver's Insurance Phone # (At Fault): Do you have health insurance? Yes No Health Insurance Company: Policy Holder Name: Phone Number: Insurance ID Number: Policy Holder Date of Birth: Attorney's Name: Phone Number: Fax: Address City State Zip Code Date of Accident: Location: Time of Day: Name of Street: Number of People in Vehicle Were You: Driver Passenger Front Seat Back Seat What direction were you driving? North South East West Direction of other vehicle? North South East West Were you wearing seat belts? Yes No Area of Impact: Behind Front Left Side Right Side Knocked unconscious? Yes No If yes, for how long? Were police notified? Yes No Were there any witnesses? Yes No Approximate speed of your car: Approximate speed of other car: Please describe the accident in your own words: Please describe how you felt during the accident: Please describe how you felt immediately after the accident: Please describe how you felt later that day: Please describe how you felt the next day: Where were you taken after your accident? Have you been treated by another doctor since this accident? Yes No If yes, whom? Please describe the type of treatment received: Did you have any physical compaints before the accident? Yes No If yes, please describe? What are your present compaints and symptoms? Since this injury occurred, are you: Improving Getting Worse No change Have you lost time from work as a result of this acident? Yes No Last Day Worked: Type of Employment: Describe, if any, activity restrictions resulting from this injury: Check all symptoms you have noticed since the accident: Headache Neck Pain Neck Stiffness Sleep Problems Back Pain Nervousness Tension Irritability Chest Pain Dizziness Head Heavy Pins/Needles-arms Pins/Needles-legs Numbness-finger(s) Numbness-toes Shortness of Breath Fatigue Depression Light sensitive eyes Loss of Memory Ears Ringing Face Flushed Buzzing in Ears Loss of Balance Fainting Loss of Smell Loss of Taste Diarrhea Cold Feet Cold Hands Stomach Upset Constipation Cold Sweats Fever Other Symptoms If you selected other symptoms, please explain: I accept that I have answered the questions on this form to the best of my knowledge. Full Name Today's Date Send
