Motor Vehicle Collision Form
Patients Name:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1) Please choose the date of the MVC:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
2) Please the time of the MVC:
Hour Minutes
AM
PM
AM/PM Option
3) Please enter the number of vehicles involved in the MVC:
1
2
3
4
5
6
7
8
9
4) In dollars, please enter the estimated damage to your vehicle
5) What road were you on?
6) What direction were you travelling in?
NW
N
NE
W
E
SW
S
SE
7) What city & state were you travelling in?
8) Please choose the primary type of impact:
vehicle was rear ended
vehicle hit another vehicle from behind
vehicle was hit on the passenger’s side
9) What did the vehicle do immediately after the accident?
hit a guardrail
hit a tree
rolled over
was run off the road
Other
10) Where were you sitting in this vehicle?
driver
rear left passenger
rear passenger
front passenger
rear right passenger
Other
11) Did you know the accident was coming
was unaware of the impending collision
was aware the impending collision and she braced herself
was aware of the collision and relaxed
Other
12) What is the type of vehicle you were in?
subcompact
car
compact car
mid-size car
full-sized car
truck
SUV
minivan
van
larger than one ton vehicle
Other
13) At the time of impact, your vehicle was:
slowing down
gaining speed
stopped
moving at a steady speed
Other
14) At impact the other vehicle involved was:
slowing down
gaining speed
stopped
moving at a steady speed
Other
15) During and after the crash, what happened to your vehicle?
kept going straight kept going straight
hitting a car in front of her
was hit by another vehicle
spun around
spun around and hit a stationary object
Other
16) Did you lose consciousness during the accident?
lost consciousness during the accident
remained conscious throughout entire accident
Other
17) How was your head positioned during the accident?
head facing forward
head turned to the left
head turned to the right
head facing upward
head facing downward
head facing to the right and upward
head facing to the right and downward
head facing left and upward
head facing left and downward
Other
18) How was your torso positioned during the accident?
torso positioned forward
torso positioned to the left
torso positioned to the right
torso extended
torso flexed
torso flexed with right rotation
torso extended with right rotation
torso flexed with left rotation
torso extended with left rotation
Other
19) How were your hands positioned during the accident?
left hand on the steering wheel
right hand on the steering wheel
both hands on the steering wheel
left hand on dashboard
right hand on dashboard
both hands on dashboard
hand on the seat in front
hands resting along side
hands on ceiling of the car
Other
20) Did your head hit any of the following?
windshield
steering wheel
side door
dashboard
ceiling
carframe
another passenger
seat
side window
Other
21) Did your face hit any of the following?
windshield
steering wheel
side door
dashboard
ceiling
carframe
another passenger
seat
side window
Other
22) Did your shoulders hit any of the following?
windshield
steering wheel
side door
dashboard
ceiling
carframe
another passenger
seat
side window
Other
23) Did your neck hit any of the following?
windshield
steering wheel
side door
dashboard
ceiling
carframe
another passenger
seat
side window
Other
24) Did your chest hit any of the following?
windshield
steering wheel
side door
dashboard
ceiling
carframe
another passenger
seat
side window
Other
25) Did your hips hit any of the following?
windshield
steering wheel
side door
dashboard
ceiling
carframe
another passenger
seat
side window
Other
26) Did your knees hit any of the following?
windshield
steering wheel
side door
dashboard
ceiling
carframe
another passenger
seat
side window
Other
27) Did your feet hit any of the following?
windshield
steering wheel
side door
dashboard
ceiling
carframe
another passenger
seat
side window
Other
28) What kind of headrests were in your vehicle?
movable fixed head restraints
fixed, non movable head restraints
no head restraints
Other
29) Where was your headrest positioned on your head?
at the top of the back of head
at the middle height of the bad of head
at the lower portion of the back of head
at the level of the back of neck
at the level of the shoulder blades
Other
30) Did you have your seatbelt on?
was wearing a shoulder strap seat belt
was wearing a lap belt seat belt
was in a baby car seat
was not wearing her seatbelt
cannot remember is she had a seat belt on
was in a booster seat
Other
31) Did you slide out of your seatbelt?
slid out of seatbelt
remained in seatbelt
partially slid out of seatbelt
Other
32) What was damaged in your vehicle?
windshield
steering wheel
dashboard
seat frame
side window
rear window
mirror
knee bolster
rear bumper
trunk
completely totaled
front left door
front right door
back left door
back right door
none
Other
33) Choose the items that dented inward during the accident?
side door
dashboard
floor board
none
Other
34) Choose the doors that would not open as a result of accident?
side door
dashboard
floor board
none
Other
35) How did you go to the hospital?
ambulance
helicopter
police car
drove herself
walking
N/A didn’t go to hospital
Other
36) Please choose the locations of your problems:
headaches
jaw
neck
upper back
shoulder
arm
elbow
wrist
hand
mid back
low back
hip
legs
knee
ankle
foot
Other
37) Were you hospitalized overnight?
Yes
No
N/A
38) At the hospital, were you prescribed pain medication?
Yes
No
N/A
39) Were you prescribed muscle relaxers at the hospital?
Yes
No
N/A
40) Did you receive stitches for any cuts?
Yes
No
N/A
41) Did you receive any of the following?
Cervical Collar
back brace
Cervical collar and back brace
n/a
42) Which x-rays were taken at the hospital?
skull
neck
midback
lowerback
foot
arm
pelvis
hips
leg
knee
shoulder
no x-rays
Other
43) Was an MRI performed?
skull
neck
midback
lowerback
foot
arm
pelvis
hips
leg
knee
shoulder
no x-rays
Other
44) Did you receive any special imaging?
skull
neck
midback
lowerback
foot
arm
pelvis
hips
leg
knee
shoulder
no special imaging
Other
Submit
Should be Empty: