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patient/CC
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Date of Injury
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Position in the vehicle
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Injury Location ( body part(s)
• • •
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Numbness/Tingling Location
• • •
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Wearing Seat Belt
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No Numbness/Tingling
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Vehicle movement, or still
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Pedestrian
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How impact occurred
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Not wearing Seatbelt
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Accident Location (street,city,s
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Approximate speed of patient's v
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Passenger Braced
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Type of Impact,where the vehicle
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Body Part Contact
• • •
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Driver Hands
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Body Movement upon impact
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Passenger did not Brace
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Loss of Consciousness
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Body Part Contacted (what)
• • •
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Went to Hospital (where)
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Body Movement Side
• • •
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Sought Treatment (where)
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Denies Loss of Consciousness
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Working at time of MVA
• • •
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Did not go to Hospital
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Current work status
• • •
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No Treatment
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Attorney Representation
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Place of employment
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Free Text Info
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