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    Personal Injury Ire Form

    Uploaded by

    BioVeda Health and Wellness Centers
    This document is a personal injury questionnaire that collects information about an accident. It requests details about the claimant such as name, contact information, insurance information, and attorney details if applicable. It then asks a series of questions to ascertain details of the accident in question like date, location, speeds, injuries, and treatment. Finally, it requests current symptoms being experienced and how the claimant's condition has changed since the accident. The goal is to gather all relevant facts about an accident and any resulting injuries for which a claim is being filed.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Personal Injury Ire Form

    Uploaded by

    BioVeda Health and Wellness Centers
    94 views2 pages
    This document is a personal injury questionnaire that collects information about an accident. It requests details about the claimant such as name, contact information, insurance information, and attorney details if applicable. It then asks a series of questions to ascertain details of the accident in question like date, location, speeds, injuries, and treatment. Finally, it requests current symptoms being experienced and how the claimant's condition has changed since the accident. The goal is to gather all relevant facts about an accident and any resulting injuries for which a claim is being filed.

    Original Title

    Personal Injury ire Form

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    © Attribution Non-Commercial (BY-NC)

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    PDF, TXT or read online from Scribd

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    This document is a personal injury questionnaire that collects information about an accident. It requests details about the claimant such as name, contact information, insurance information, and attorney details if applicable. It then asks a series of questions to ascertain details of the accident in question like date, location, speeds, injuries, and treatment. Finally, it requests current symptoms being experienced and how the claimant's condition has changed since the accident. The goal is to gather all relevant facts about an accident and any resulting injuries for which a claim is being filed.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    94 views2 pages

    Personal Injury Ire Form

    Uploaded by

    BioVeda Health and Wellness Centers
    This document is a personal injury questionnaire that collects information about an accident. It requests details about the claimant such as name, contact information, insurance information, and attorney details if applicable. It then asks a series of questions to ascertain details of the accident in question like date, location, speeds, injuries, and treatment. Finally, it requests current symptoms being experienced and how the claimant's condition has changed since the accident. The goal is to gather all relevant facts about an accident and any resulting injuries for which a claim is being filed.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Personal Injury Questionnaire

    Name_________________________________________________Date________________________________
    Phone(Home)_____________________(Work)_________________________(Cell)______________________
    Address______________________________________City______________________State___Zip__________
    Age_________Birthdate___________________________Sex__________SS#___________________________
    Your Auto Ins. Co._______________________________________________Policy #_____________________
    Agent’s Name______________________________________________________________________________
    Name on Policy (If other than self)______________________________________________________________
    Responsible Party’s Name____________________________________________________________________
    Address______________________________________City______________________State___Zip__________
    Policy Holder’s Name_______________________________________Policy#___________________________
    Attorney Information
    Name_________________________________________________Phone_______________________________
    Address______________________________________City______________________State___Zip__________
    Nature of Accident
    1. Date of Accident_________________________________________Time of Day_______________________
    2. Were you: __Driver __Passenger __Front Seat __Back Seat
    3. Number of people in your vehicle?___________________Were you wearing a seat belt?________________
    4. What direction were you headed? __North __East __South __West
    5. Name of street____________________________________________________________________________
    6. Were you struck from: __Behind __Front __Driver’s side __Passenger side
    7. Approximate speed of your car ____________mph Other car_____________mph
    8. Were you knocked unconscious? ___YES ___NO If yes, for how long? __________________
    9. Were police notified? ___YES ___NO
    10. In your own words, please describe the accident: _______________________________________________
    __________________________________________________________________________________________
    __________________________________________________________________________________________
    11. Did you have any physical complaints BEFORE THE ACCIDENT? YES or NO If yes, please explain:
    __________________________________________________________________________________________
    __________________________________________________________________________________________
    12. Please describe how you felt:
    a. DURING the accident:_______________________________________________________________
    b. IMMEDIATELY AFTER the accident:__________________________________________________
    c. LATER THAT DAY:________________________________________________________________
    d. THE NEXT DAY:__________________________________________________________________
    13. What are your PRESENT complaints and symptoms?___________________________________________
    _________________________________________________________________________________________
    _________________________________________________________________________________________
    14. Do you have any congenital (from birth) factors which relate to this problem? YES or NO If yes, describe:
    _________________________________________________________________________________________
    15. Do you have any previous illnesses which relate to this case? YES or NO If yes, please describe:
    _________________________________________________________________________________________
    16. Have you ever been involved in an accident before? YES or NO If yes, please describe including date(s)
    and type(s), as well as injury(ies) received._______________________________________________________
    _________________________________________________________________________________________
    _________________________________________________________________________________________
    17. Where were you taken after this accident?____________________________________________________
    18. Have you been treated by another doctor since this accident? YES or NO If yes, please list doctor’s name
    and address:______________________________________________________________________________
    What type of treatment did you receive?________________________________________________________
    ________________________________________________________________________________________
    19. Since this injury occurred, are your symptoms: __Improving __Getting worse __Same
    20. Circle symptoms that you have noticed since your accident:
    Headache Irritability Numbness in Toes Face Flushed Feet Cold
    Neck Pain Chest Pain Shortness of Breath Buzzing in Ears Hands Cold
    Neck Stiff Dizziness Fatigue Loss of Balance Stomach Upset
    Depression Tension Constipation Fainting Sleeping Problems
    Back Pain Loss of smell Light bothers eyes Ears ringing Pins and Needles in Legs
    Nervousness Fever Diarrhea Numbness in Fingers Pins and Needles in Arms
    Symptoms other than above:___________________________________________________________________
    21.Have you lost time from work as a result of this accident? YES or NO
    22. Do you notice any activity restrictions as a result of this injury? YES or NO If Yes, please describe in
    detail: ____________________________________________________________________________________
    __________________________________________________________________________________________
    23. Other pertinent information: _______________________________________________________________
    __________________________________________________________________________________________
    __________________________________________________________________________________________
    __________________________________________________________________________________________

    ___________________________________ ____________________________________
    Date Signature

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