Vehicle Incident Assessment Form

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Name:

Date of accident:

Date of first visit in the office regarding this accident:

Time and place of accident:

1) Were you using seat belts?
Head rests?

2) Was your body thrown around?
(Please specify which part of your body was struck and in which direction)

3) Describe the sensation you felt:
Immediately after the impact:

One hour later:

That evening:

The next day:

4) Have other symptoms appeared since the accident?

5) How long after the accident did they appear?

6) Were you taken to the hospital? Yes / No
7) What is your course of treatment with other Doctors, Physiotherapists,
Chiropractors, medication, X-rays, etc.

8) What is your major complaint?

9) How long did it last?

10) Any other symptoms (nausea, headache, etc.)

11) How long did these last?

12) Did you experience?
Tingling or numbness in the extremities?
Dizziness?
Fatigue?
Other? _________________________________
13) Describe the accident:


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