Cornerstone Chiropractic
Auto Accident Report Form
Name:
Date of Accident:
Were you the:
Were you struck from:
Did your car strike theirs?
Did the other car strike yours?
Were you wearing your seatbelt?
Did you have a shoulder strap?
Did your seat have a headrest?
Did you lose consciousness?
Did you hear any popping, tearing, or ripping noise in your nack or back?
Did you feel pain?
How long after accident?
Please check any new symptoms you have experienced since the accident:
Did you require emergency care or hospitalization?
Did you receive X-Rays?
Describe the treatment given:
Describe the accident in detail (include time, road conditions, street names, speed of vehicles etc.):
Your Insurance company:
Other driver's insurance company:
Claim number (from your insurance company):
DriverPassengerPedestrian
BehindDriver's sidePassenger's sideFront
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Headaches
Skull or Head Pain
Neck Pain
Neck Stiffness
Head feels heavy
Shoulder Pain
Shoulder Stiffness
Arm Pain
Arm Numbness
Pins and needles in arm
Numbness in hands/fingers
Cold Hands
Upper Back Pain
Upper Back Stiffness
Mid Back Pain
Mid Back Stiffness
Chest Pain
Rib Pain
Painful/Difficult Breathing
Low Back Pain
Low Back Stiffness
Hip Pain
Buttock Pain
Leg Pain
Leg Numbness
Pins and needles in legs
Numbness in Feet/Toes
Cold Feet
Depression
Anxiety
Tension
Irritability
Mental Dullness
Loss of Memory
Difficulty Sleeping
Tremors
Loss of Color
Dizziness
Fainting
Loss of smell
Pain behind the eyes
Sensitivity to light
Loss of Balance
Digestive Problems
Nausea
Vomiting
Diarrhea
Constipation
Difficulty with:
Riding in Car
Bending
Standing
Sitting
Walking
Lifting
Twisting/Turning
Yes No
Yes No