AuJTO I \X/012Jl R:~LA T,~D AGCli;>~NJ;

{ AE:>OUT YOU

Today's Date: __ / __ / _ File#: _______ _

Name: ------------------

Date & Time of Accident: ___ __ _ 0 a.m. 0 p.m. Was your accident directly related to your work?

O Yes O No Briefly describe the events that occurred just before and

during your accident: ____________ _

Give the address where accident occurred: (if other than

employer's address) ____________ _

Was anyone else present during your accident? o Yes O No

Did you report your accident to your employer? o Yes o No

What recommendations did your employer make just

after your accident? ____________ _

Has this type of accident happened to you before? □ Yes O No

To the best of your knowledge, has this accident occurred in your workplace before? ............. 0 Yes O No In general:

Is your job physically stressful? ........ O Yes O No Is your job mentally stressful? .......... 0 Yes O No Is your workplace noisy? ......... ... .. 0 Yes O No Have you changed jobs in the last year? 0 Yes O No

AUTO Q.1:_LA Tl:_D ACCIDl:_NT

Date & Time of Accident: Oa.m . Op.m . Were you the: 0 Driver O Front Passenger O Rear Passenger If a traffic violation was issued, to whom was it issued?

-

Number of people in accident vehicle? --

Did the police come to the accident site? . . 0 Yes □ No Was a police report filed? ..... .. ....... 0 Yes □ No Were there any witnesses? ... ... .... .. . 0 Yes □ No Were you wearing your seat belt? ....... □ Yes □ No Was this vehicle equipped with airbags? .. □ Yes □ No If yes, did it/they inflate? ............... o Yes □ No In relation to the base of your skull, where was the headrest? ....... 0 Above 0 Below O At base of skull What did your vehicle impact? O Another vehicle □ Other

If other, explain: Did any part of your body strike anything in the vehicle?□ Yes O No

If yes, please describe:

Make & model of the vehicle you were occupying?

Name of the location/street on which you were traveling?

In which direction were you headed? ON OS OE OW

What was the approx. speed of your vehicle? Did the impact to your vehicle come from the: O Front O Rear 0 Right Side 0 Left Side 0 Other

During impact, were you facing: □ Right □ Left □ Forward

Were you O aware or O surprised by the impact? If accident vehicle made impact with another vehicle ...

Make and model of that other vehicle?

Direction other vehicle was headed? ON OS OE OW

Speed of the other vehicle?

In your words, please describe the accident:

PLb..A.:>b.. CONTINUb.. ON E>ACil

.;~ AfT~R. INJURY

Did accident render you unconscious? ..... □ Yes □ No

If yes, for how long? Please describe how you felt immediately after the accident:

Have you gone to a Hospital or seen any other Doctor?□ Yes □ No When did you go? □ Just after accident □ The next day □ 2 days plus How did you get there? □ Ambulance or □ Private transportation

Name of Hospital and/or Attending doctor: __ _

Was he/she a: □ D.C. □ M.D. 0 D.O. 0 D.D.S.

Describe any treatment you received: ______ _

Were X-rays taken? .............. . .. . ... . . ... □ Yes O No Was medication prescribed? .... .. . . ..... □ Yes □ No Have you been able to work since this injury?□ Yes □ No Are your work activities restricted as a result of this injury?

□ Yes □ No Indicate ~ the symptoms that are a result of this accident: □ Dizziness □ Difficulty sleeping □Jaw problems □ Nausea □ Memory loss □ Irritability □ Arms/Shoulder pain □ Back pain □ Headache(s) □ Fatigue □ Numb Hands/Fingers □ Lower back pain □ Blurred vision □Tension □ Chest pain □ Back stiffness □ Buzzing in ear □ Neck pain □ Shortness of breath □ Leg pain □ Ears ringing □ Neck stiff □ Stomach upset □Numb Feet'Toes □ Other

Is your condition getting worse? 0 Yes O No O Constant O Comes & goes

Indicate your degree of comfort while performing the following activities:

Comfortable Uncomfortable Painful even if only sometimes

Lying on back .... .. .. . □ ...... .... □ . .... .. 0 Lying on side . ... .. ... □ ..... .... . □ ....... □ Lying on stomach ...... □ ....... ... □ ....... 0 Sitting ...... . .... . ... □ .......... □ ....... □ Standing . .. .. ...... . . 0 . . ........ 0 ....... 0 Stretching ... . ........ 0 .......... O .... . .. O Lovemaking . ....... . . 0 . ......... O ....... 0 Walking ... . . .. . . . . .. □ .......... □ ... .... □ Running . .. . . . .... . .. □ . .... .. ... □ ..... .. □ Sports ... . .. .. . . ..... □ .......... □ ....... □ Working ... .... . ..... 0 ....... . .. O . ...... O Lifting .. .. ..... . ..... 0 . . ..... . . . 0 ....... 0 Bending .. ..... .. . .. . 0 ... . ..... . O ....... O Kneeling ........ . .... 0 ... . ...... 0 ..... .. 0 Pulling ..... . .. .. ... . 0 .. . ....... O .... . .. O Reaching . .. . ....... . 0 .. . ....... □ .... .. . □ Have you retained an attorney: □ Yes □ No

If yes , whom:

His/Her Phone#: _____________ _

First Impression Forms, Inc 1-800-99FORMS FORM# 2CAWA1 copyright© 1996

To evaluate the effect that continuing work will have on your recovery please complete the following: How many hours are in your normal work day? Please indicate !if your daily job duties and any activities which you are occasionally asked to perform . 0 Standing □ Driving □ Operating equipment 0 Sitting □ Twisting O Work with arms above head 0 Walking □ Crawling O Typing □ Lifting □ Bending □ Stooping

0 Other What positions can you work in with minimum physical

effort and for how long? __ ON/A Prior to the injury were you capable of working on an equal basis with others your age? . . 0 Yes O No ON/A

heavy lifting? ... . ...... . . . . .. .. □ Yes □ No □ N/A IDo you work with others who can help you with any

While in recovery, is there any light duty work you could request? ......... ... ... ... ... □ Yes □ No □ N/A

Type of Insurance :_

Co. Name:

Address:

Phone#: __ _

lnsured's Name: ______ _

I Policy#: ______ _ Claim#:

lnsured's SS #: _____ _

lnsured's Employer:

Agent's Name:

D.O .B. I I

If any of your medical or account information has changed, I please inform our front desk personnel. Please remember you are ultimately responsible for your I account.

I I SIGNATURE DATE

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