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Date of Injury
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Attorney Representation
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Accident Location
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Position in the vehicle
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Pedestrian
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Wearing Seat Belt
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Not wearing Seatbelt
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How impact occurred
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Approximate speed at impact
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Vehicle movement, or still
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Type of Impact,where the vehicle
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Body Movement upon impact
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Body Movement Side
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Body Part Contact
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Body Part Contacted (what)
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Airbags deployed
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Airbags did not deploy
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Loss of Consciousness
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Denies Loss of Consciousness
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Injury Location ( body part(s)
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Went to Hospital (where)
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Did not go to Hospital
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Sought Treatment (where)
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No Treatment
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Numbness/Tingling Location
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No Numbness/Tingling
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Current work status
• • •
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Free Text Info
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