CONFIDENTIAL PATIENT INFORMATION                                               Date____________________ AUTO Legal Name Home Phone Address (No. & St.) City Zip Social Security No. Birthdate. Employer Address City State Zip Employer Phone Cal Drivers Lic. No. Spouse's Name Phone Date of Accident: Time (approx) AM PM You were traveling N S E W on and you were struck from Behind Front Left Side You were stopped/ traveling approx MPH. Other driver was stopped/ traveling approx MPH. You were driving a . Other vehicle was a . Damage to your vehicle was (approx) $ . Vehicle is registered to . You were the Driver Passenger Back Seat. You were wearing Shoulder Harness Lap Belt No Restraints Air bag Did Did not deploy. Police report was was not made. You Did Did not see the accident about to happen. Your foot was on the brake gas pedal when the accident occurred. You were looking Forward To the Right To the Left when the accident occurred. Were you thrown about the car? Yes No. Did you hit the steering wheel? Yes No. The windshield? Yes No. You were taken to Hospital/Clinic in the city following the accident, where you received Medication Xrays MRI Other . OTHER 1. You continued your day as usual 2. You went home to rest 3. You were taken to a friend's house 4. Immediately following the accident you felt Shock Neck Pain Headache Low Back Pain Dizziness Visual Disturbances Tingling Hands Shoulder Pain Right Left Chest Pain Tingling in Feet Shallow Breathing Lost Consciousness Yes No Elbow Pain Right Left Wrist Pain Right Left Knee Pain Right Left PRINT this page and then go on to Page 2.