Personal Injury Questionnaire |
Name:
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Address:
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City:
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Home Phone:
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Work Phone:
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E-Mail Address:
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Fax:
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Date of Accident:
(mm/dd/yy)
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Location of Accident:
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Did the police respond to your accident?
Yes
No
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If so, do you have a police report?
Yes
No
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Were you examined or treated at a hospital emergency room?
Yes
No
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Were you hospitalized?
Yes
No
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Did you see a doctor as a result of your injuries?
Yes
No
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Are you currently under a doctor's care for injuries sustained in this accident?
Yes
No
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How much time, if any, did you lose from work or school?
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Description of Accident:
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Describe Your Injuries:
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For motor vehicle accidents, describe the damage to the vehicles:
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