Fort Lauderdale Injury Doctor , Auto Accident Intake Form

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About Your Auto Accident  Injury 

1. Were you in an Auto Accident?

2. When were you injured?

3. What are your injuries?

4. Who was ticketed or found at fault for the accident?

5. Did the  police come to the scene of the accident? Is there a police report?

Automobile Accident Questionnaire

Date of Injury: City of Injury:

Were you the driver or passenger?:

Where were you seated in the car?:

Were you wearing a seat belt?     Yes   No   Was it equipped with a shoulder harness?     Yes   No

What was the mechanism of injury (rear impact, side impact, front impact)?

Did your air bags deploy?    Yes   No  

Was there a secondary impact (another car, a curb or barrier, etc.)?

Were you prepared for the impact?    Yes   No  

Did you strike any part of your body on the interior of the car? (What and Where)

Did you lose consciousness?  Yes   No  How long?

Were you attended to by an EMT?    Yes   No  

Were you taken to the hospital?  Yes   No  Which Hospital?

IF YES: By ambulance or other transportation?

Were x-rays performed?  Yes   No  What body areas?

Were you admitted over night?    Yes   No  

Were you given orthopedic supports or braces?  Yes   No  What type?

Were you given medications or prescriptions?  Yes   No  What type?

What were your discharge instructions? (No work, rest, home care, follow-up, exercise etc.)

Have you had any other medical care since the injury?    Yes   No  

Doctor or clinic name:

When consulted:


Have you had any diagnostic tests since the accident? (MRI, CT Scan, Bone Scan, X-Ray etc)

Have you had any previous accident or injuries?  Yes   No  When?

Have you missed days from work?  Yes   No  How many ?

Thank you for completing your Auto Accident  intake form.