Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Motor Vehicle Accident Intake Form
Motor Vehicle Accident Intake Form This form documents your motor vehicle accident for medical and insurance purposes. Please provide complete and accurate details about the accident and your injuries. This information is critical for your treatment plan and any related claims.
Full Name *
Date of Birth *
____ / ____ / ________
Email Address *
Phone Number *
Date of Accident *
____ / ____ / ________
Time of Accident *
____ : ____ AM / PM
Accident Details & Injury Assessment Please describe the accident circumstances and any injuries or symptoms you have experienced.
Describe the Accident *
Your Role in the Accident *
- Driver
- Passenger
- Pedestrian
- Cyclist
Were You Wearing a Seatbelt? *
- Yes
- No
Did Airbags Deploy? *
- Yes
- No
Did You Lose Consciousness? *
- Yes
- No
Were You Taken to the Emergency Room? *
- Yes
- No
Body Parts Injured *
- Head
- Neck
- Shoulder
- Upper Back
- Mid Back
- Lower Back
- Chest
- Arm
- Wrist
- Hip
- Knee
- Ankle
Symptoms Since the Accident *
- Headache
- Neck Pain
- Back Pain
- Dizziness
- Nausea
- Numbness
- Tingling
- Blurred Vision
- Memory Issues
- Sleep Disturbance
Current Pain Level (1-10) *
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Was a Police Report Filed? *
- Yes
- No
Is an Attorney Involved? *
- Yes
- No
Auto Insurance Company
Claim Number
Previous Car Accidents
Pre-existing Conditions
- Diabetes
- Hypertension
- Asthma
- Heart Disease
- Cancer
- None
Current Medications
Motor Vehicle Accident Intake Form template from formisoft.com. formisoft.com/intake-templates/mva-intake