Family First Chiropractic - Chiropractor In Sparks, NV, USA

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Home > New Patient Center > New Patient Submit email > Auto Accident Information

Auto Accident Information

Date of accident: *

Time of accident: *

How many vehicles were involved? *

What was the estimated damage of your vehicle? *

What direction were you traveling? *

What street or intersection were you on when the accident occured? *

What city and state were you in? *

Were you struck from: *

Behind FrontLeft SideRight Side

What was your location in the vehicle? *

DriverFront passengerRear passenger

Rear passenger location?

Did you know the accident was coming? *

YesNo

What kind of vehicle were you in? *

CarSUVPick UpVanOther: __________________________________

Vehicle SIze: *

Full Size Mid Size Compact Other: __________________________________

What kind of vehicle was involved?

CarSUVPick UpVanOther: __________________________________

Vehicle Size:

Full SizeMid SizeCompactOther: __________________________________

How fast was your vehicle going? *

Were you: *

Slowing downSpeeding upSteady PaceStopped/Parked

If another vehicle was involved, how fast was it going?

Was the vehicle:

Slowing DownSpeeding UpSteady PaceStopped/Parked

During the crash, what happen to your vehicle? (check all that apply) *

Kept going straightSpun aroundKept going straight, hitting a car in frontSpun around and hit a staionary objectWas hit by another vehicleHit a stationary objectOther: __________________________________

Did you lose conciousness during the accident? *

Yes No

How was your head positioned during the accident? *

How was your torso positioned during the accident? *

How were your hands positioned during the accident? *

Did your head hit anything during the accident? (If yes, please explain) *

Did your face hit anything during the accident? (If yes, please explain) *

shouDid your lders hit anything during the accident? (If yes, please explain) *

Did your neck hit anything during the accident? (If yes, please explain) *

Did your chest hit anything during the accident? (If yes, please explain) *

Did your hips hit anything during the accident? (If yes, please explain) *

Did your knees hit anything during the accident? (If yes, please explain) *

Did your feet hit anything during the accident? (If yes, please explain) *

What kind of headrest was in your vehicle? *

Movable fixed headrestNonmovable fixed headrestNo headrest

Where was the headrest positioned on your head?

Were you wearing your seat belt? *

YesNo

If yes, please explain:

Shoulder-Lap beltShoulder beltLap belt

Did you slide out of your seat belt during the accident? *

YesNo

What was the damage to your vehicle? (Check all that apply) *

WindsheildRear BumberMirrorSteering WheelFront BumperKnee BolsterDashboardTrunkBack Right DoorSeat FrameFront Left DoorCompletely TotaledSide WindowFront Right DoorRear WindowBack Left DoorOther: __________________________________

Enter the verification code in the box below.

Verification Code: *

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