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Motor Vehicle Accident Intake Form

3 pages•22 fields•HIPAA-ready
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formisoft.com/f/mva-intake
Patient Full Name
Date of Birth
Date of Accident
Accident Location
Were You the Driver or Passenger
Were You Wearing a Seatbelt
Did Airbags Deploy
Describe How the Accident Occurred
Current Symptoms
Pain Level (1-10)
Auto Insurance Company
Patient Signature
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The Motor Vehicle Accident Intake Form captures all critical details of a motor vehicle collision and the resulting injuries. It documents the accident circumstances including date, location, speed, point of impact, seatbelt and airbag usage, and whether the patient was the driver or passenger. This thorough accident reconstruction information is essential for clinical correlation and supports personal injury documentation requirements.

The form includes comprehensive symptom assessment fields covering common MVA injuries such as neck pain, headaches, back pain, numbness, dizziness, and cognitive symptoms. It captures auto insurance details, attorney information if applicable, and whether a police report was filed. Pre-existing conditions and prior accidents are documented to establish baseline health status, which is critical for personal injury cases.

Widely used by chiropractic offices, physical therapy clinics, orthopedic practices, pain management centers, and emergency departments. This form serves as the foundation for personal injury documentation and helps providers create thorough medical-legal records that support the patient's treatment plan and any associated insurance or legal proceedings.

What's included

  • Detailed accident circumstances and vehicle information
  • Safety device usage (seatbelt, airbag, headrest)
  • Comprehensive symptom checklist for common MVA injuries
  • Pain scale and body location documentation
  • Auto insurance and attorney information
  • Police report and emergency room visit documentation
  • E-signature capture

Who uses this template

  • Chiropractic initial evaluation after auto accidents
  • Physical therapy intake for MVA-related injuries
  • Orthopedic assessment of collision-related musculoskeletal injuries
  • Pain management evaluation for post-accident chronic pain

All form fields

12 fields across 3 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Date of AccidentDate
Accident LocationText
Were You the Driver or PassengerMultiple Choice
Were You Wearing a SeatbeltMultiple Choice
Did Airbags DeployMultiple Choice
Describe How the Accident OccurredLong Text
Current SymptomsCheckbox
Pain Level (1-10)Multiple Choice
Auto Insurance CompanyText
Patient SignatureE-Signature

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Sign up and start customizing the Motor Vehicle Accident Intake Form for your practice. 30-day money-back guarantee.

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$79.99/mo · Cancel anytime · HIPAA compliant

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