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info@shawchiropractic.com

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Information for Attorneys
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Information for Patients
Patient Forms
- Fill the form online
- Download the PDF forms
Blog
Mobile App
Contact Us

Automobile Accident Questionnaire

PERSONAL INFORMATION

Name / Nombre *

Gender / Género *

Male / Masculino
Female / Femenino

Today’s Date / La Fecha de Hoy *

Your Birth Date / Fecha de Nacimiento *

Date of Accident / Fecha del Accidente *

Town of Accident / Ciudad del Accidente *

State of Accident / Ubicación del Accidente *

Were You The Driver or Passenger? / Era usted el conductor o un pasajero? *

Driver / Conductor
Passenger / Pasajero

Were You Wearing a Seatbelt? / Tenía su cinturon de seguridad puesto? *

Yes / Si
No / No

Was The Seatbelt Equipped With a Shoulder Harness? / Estaba equipado con un arnés del hombro? *

Yes / Si
No / No

Was The Head Restraint (Headrest) Adjusted? / Estaba el apoyo de la cabeza ajustado? *

Yes / Si
No / No

What Was The Seat Position? / Cuál era la posición del asiento? *

Vertical/90º / Vertical 90 Grados
Reclined / Inclinado

INJURY INFORMATION

What Was the Mechanism of Injury? / Cuál fué el mecanismo del acidente? *

Rear / Por Detras
Side / De Lado
Front / De Frente
Other / Otro

Did the Airbag Deploy? / Se saleron las bolsas de aire? *

Yes / Si
No / No
No Airbags / No bolsas de aire

Where you Prepared for Impact? / Estaba preparado(a) para el impacto? *

Yes / Si
No / No

Was there a secondary Impact (other car, curb, barrier, etc)? / Hubo un impacto secundario (otro carro, un encintado o una barrera, una acera, etc.)? *

No / No
Yes / Si

What?

What direction was your head turned at impact? / En qué dirección estaba su cabeza o cuerpo girada/o durante el impacto? *

If you were wearing glasses or a hat, where did they end up after the impact? / Si usted tenía lentes o un sombrero puesto dónde quedaron después del impacto? *

Did you lose consciousness? / Perdió el conocimieto? *

No / No
Yes / Si

How Long? / Por cuánto tiempo?

Did you strike any part of your body on the inside of the car? If so, what/where? / Se lastimó alguna parte de su cuerpo con el interior del auto? (Qué, Dónde) *

No / No
Yes / Si

Where? / Dónde?

Did an EMT Attend to You? / Fué atendido por un Paramédico? *

Yes / Si
No / No

Were you taken to The Hospital? / Fué llevado al Hospital? *

No / No
Yes / Si

Which Hospital? / Cuál Hospital?

Were you Taken by Ambulance? / En ambulancia u otro transporte? *

Yes / Si
No / No

Were you X-Rayed? / Le radiografiaron? *

No / No
Yes / Si

If X-Rayed, What Body Part(s)? / Qué áreas del cuerpo?

Were you Admitted Overnight? / Lo(a) admitieron por la noche? *

Yes / Si
No / No

Were you given Medication or Prescriptions? / Recibió alguna prescripción médica? *

No / No
Yes / Si

Were you given Medication or Prescriptions? / Recibió alguna prescripción médica?

Were you given any Orthopedic Supports or Braces? / Recibió algun supporte ortopédico? *

Yes / Si
No / No

What were your discharge instructions? Work, Rest, Exercise. / Cuáles fueron sus instrucciones de salida? trabajo, descanso, ejercicio. *

Have you had any other medical care since the accident? / Ha tenido otra asistencia médica desde el accidente? *

No / No
Yes / Si

When Consulted? / Cuándo fué consultado(a)

Name of Doctor or Clinic / Nombre del Doctor o de la Clínica *

Treatment Received / Tratamiento *

Have you had any diagnostic tests since the accident? (MRI, CT Scan, Bone Scan, X-Ray etc.) / Has tenido pruebas de diagnóstico desde el accidente? (MRI, Escanografía ósea, Radiografía etc.) *

No / No
Yes / Si

Have you had any diagnostic tests since the accident? (MRI, CT Scan, Bone Scan, X-Ray etc.) / Has tenido pruebas de diagnóstico desde el accidente? (MRI, Escanografía ósea, Radiografía etc.)

Have you tried any home treatments like hot packs, medication, massage, etc? Were they successful? / Has intentado tratamientos caseros? (Paños Calientes,Medicamento,Masajes etc.? ¿Fueron eficaces? *

No / No
Yes / Si

Have you tried any home treatments like hot packs, medication, massage, etc? Were they successful? / Has intentado tratamientos caseros? (Paños Calientes,Medicamento,Masajes etc.? ¿Fueron eficaces?

Have you missed work? / Has faltado al trabajo? *

Yes / Si
No / No

From / De *

To / A *

Other Information / otra información *

Phone

The safest source for practitioner-grade supplements.

HARTFORD

HARTFORD
36 Grand St
Hartford, CT 06106
860.522.2225
Fax: 860.493.2509

NEW BRITAIN

NEW BRITAIN
136 West Main St
New Britain 06052
860.225.7429
Fax: 860.826.4762

EAST HARTFORD

EAST HARTFORD
290 Roberts St
East Hartford, CT 06108
860.290.3788
Fax: 860.290.3789

MIDDLETOWN

MIDDLETOWN
62 Washington Street, 3rd Flr
Middletown, CT 06456
860.788.3975
Fax: 860.788.3631

BLOOMFIELD

BLOOMFIELD
701 Cottage Grove Road, C10
Bloomfield CT 06002
860-904-6685
Fax: 860-904-6783

The information on this website was written as advertising material and is intended for general information purposes only. Nothing on this site should be taken as medical advice for any individual case or situation. This information is not intended to create, and receipt or viewing does not constitute, a doctor-patient relationship. © 2021 Shaw Chiropractice Group by Legal Soft

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Automobile Accident Questionnaire

PERSONAL INFORMATION

INJURY INFORMATION

HARTFORD

NEW BRITAIN

EAST HARTFORD

MIDDLETOWN

BLOOMFIELD

info@shawchiropractic.com

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