Injury Type:
Client Contact:
Client info:
Who is you primary care physician?
Insurance:
If Homeowners Claims:
The Crash / Property Damage:
Witnesses:
Bodily Injury:
Position / activity before impact (neck turned/hands on wheel/drinking water/etc)?
Position / activity during impact (hit head/wrist buckled/etc)?
Feelings/emotions/pain immediately after crash:
Symptoms, pain and current injuries:
Hobbies/Activities/Clubs:
How has this impacted daily life / activities client cannot do or has pain with / etc:
Things not able to do anymore with friends, spouse, kids anymore (if applicable):
Have your injuries affected your spouse or kids?:
Treatment:
List Prior/Current Treatment Facilities:
If yes, when? With which insurance company? Did you hire a lawyer? When was this claim resolved?
Witnesses: