ACCIDENTAL INJURY REPORT
If your clinic visit is due to an accident, please describe all events associated with it.
DATE OF ACCIDENT _____________________________________ HOUR OF ACCIDENT ________________________ AM / PM
TYPE OF ACCIDENT :  WORK RELATED
 TRAFFIC
 OTHER
WORK RELATED ACCIDENT
EMPLOYER ____________________________________________ TYPE OF BUSINESS____________________________________
WAS ANY EQUIPMENT, MACHINERY AND/OR OBJECT RELATED TO ACCIDENT? WHAT KIND? ____________________
WAS ACCIDENT REPORTED TO SUPERVISOR AND/OR EMPLOYER?
HAS A WOKER’S COMPENSATION CLAIM BEEN FILED?
 YES
 NO
 YES  NO
TRAFFIC ACCIDENT
WHAT KIND OF VEHICLE WAS INVOLVED IN ACCIDENT?
WERE YOU A
 DRIVER  PASSENGER
 TRUCK  CAR  MOTORCYCLE  OTHER
 PEDESTRIAN?
IF A PASSENGER, PLEASE INDICATE YOUR LOCATION IN THE CAR _______________________________________________
 YES  NO MPH? ________________________
WAS YOUR VEHICLE MOVING WHEN THE ACCIDENT OCCURRED?
DID YOUR VEHICLE HIT OTHER VEHICLE/S
 YES  NO
WHERE? ___________________________________________
DID OTHER VEHICLE/S HIT YOUR VEHICLE?  YES  NO WHERE?
WAS ACCIDENT REPORTED TO POLICE DEPARTMENT?
WERE TRAFFIC CITATIONS ISSUED?  YES  NO
 YES
___________________________________________
 NO
TO WHOM?_________________________________________________
WHERE DID ACCIDENT OCCUR ? ______________________________________________________________________________
DESCRIBE ACCIDENT INCLUDING CAUSE/S AND SURROUNDING CIRCUMSTANCES ______________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
PRESENT COMPLAINT
 PROLONGED CAR RIDING
 FACE PALE
 LOSS OF SMELL
 PINS & NEEDELS IN ARMS/LEGS
 DIZZINESS
 DEPRESSION
 ANXIETY
 EYES SENSITIVE TO LIGHT
 NECK MOTION RESTRICTED
 HEAD SEEMS TOO HEAVY
 EXCESS PERSPIRATON
 SINUS TROUBLE

NUMBNESS IN FINGERS, ARMS, LEGS
 FAINTING
 SWOLLEN ______
 EXTREME FATIGUE
 EYES LOSS OF FOCUS
 UPPER BACK PAIN/STIFFNESS

HEAD & SHOULDERS TIRED & HEAVY
 DIGESTIVE DISORDERS TREMORS
 EXTREME
 CHEST PAIN
 DOUBLE VISION
 NERVOUSNESS
 INSOMNIA
 NAUSEA, VOMITING
 FEET/HANDS
 MENTAL DULLNESS
 PALPITATION
 COLD
 SHORTNESS OF BREATH
 EARS BUZZING/RINGING
 MID BACK PAIN/STIFFNESS
 NEURITIS
 DIARRHEA
 TENSION
 LOSS OF MEMORY
 NECK PAIN
 DIFFICULTY IN
 EYE STRAIN
 LOSS OF TASTE
 LOW BACK PAIN/STIFFNESS
 FACE FLUSHED
 CONSTIPATION
 IRRITABLIT
 EQUILIBRIUM PROBLEMS
 NECK STIFFNESS
 PAIN BEHIND EYES
 DIFFICULTY IN EXCESSIVE  STANDING  WALKING  RIDING  BENDING
 NECK, LOW BACK PAIN & STIFFNESS UOPN RISING
 PAIN RADIATING INTO  RIGHT ARM RIGHT LEG BOTH LEFT LEG LEFT ARM  BOTH
 DIFFICUILTY IN EXCESSIVE LIFTING  LIGHT  MODERATE  HEAVY  REPETITIVE
 PAIN RADIATING INTO  NECK  BASE OF SKULL  SHOULDER  ARMS  HIPS LEGS
DID YOU REQUIRE POST-ACCIDENT HOSPITALIZATION  YES  NO IF SO, WHERE?____________________
HAVE YOU HAD SIMILAR ACCIDENTS OR INJURIES BEFORE?  YES  NO
SYMPTOMS OTHER THAN ABOVE ______________________________________________________________________
______________________________________________________________________________________________________
INSURANCE COMPANIES INVOLVED
PARTY RESPONSIBLE FOR PAYMENT _________________________ CLAIM # _________________________________
HAVE YOU BEEN CONTACTED BY AN INSURANCE ADJUSTER OR COMPANY REPERSENTATIVE ABOUT CLAIM?
____________________________________________________
HAS YOUR ATTORNEY ADVISED YOU IN THIS CASE
 YES
 NO
ATTORNEY’S NAME, ADDRESS & TELEPHONE # _________________________________________________________
PATIENT’S SIGNATURE ______________________________________________________ DATE ____________________