Vehicle Incident Assessment Form

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 / No7) 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: