Type of Accident

Motor Vehicle

Where were you sitting?
Which restraints were used? (Check all that apply)
Did your vehicle hit another object?
Or did other vehicle hit your vehicle?
If yes, where was your vehicle hit?
Did you experience whiplash?
Did you hit your head?

Other Accidents

Toxic

Anoxic

Vascular

Other

Head Injury Description

What part(s) of your head was/were affected? Choose all that apply.
Were you unconscious?

Initial Care

Did you see a doctor concerning the accident?

Subsequent/Other Professional Care

What kind of professional care for your injuries/trauma have you received or are you receiving?

Symptoms immediately following the accident

Difficulties Following Accident

Other Information

I authorize the release of medical and/or other information pertinent to my care to the insurance company in order for me to be reimbursed.

Subsequent Symptoms/Experiences

Please consider each symptom and check that apply. Place check for MIN if the symptom is only minimally present or MAX if the symptom is very significant

Blurred Vision, Distance Viewing
Blurred Vision, Near Viewing
Slow to shift focus, near to far to near
Difficulty taking notes
Putting or tugging sensation around eyes
Difficulty moving or turning eyes
Pain with movement of the eyes
Wandering eye
Double Vision
Loss of place while reading
Discomfort while reading
Unable to sustain near work/reading for adequate periods
General fatigue while reading
Eyes get tired while reading
Headaches
Pain in or around eyes
Easily distracted
Decreased attention span
Reduced concentration ability
Difficulty remembering what has been read
Difficulty remembering names of objects
Difficulty remembering people's names
Difficulty recalling information known in the past
Difficulty recognizing formerly familiar objects
Difficulty recognizing formerly familiar people
Difficulty remembering things heard
Difficulty remembering things seen
Dizziness
Poor coordination
Clumsiness
Loss of balance
Poor eye-hand coordination
Poor handwriting
Poor posture
Head tilt
Face turn
Covering, closing one eye
Disorientation
Get lost often
Bothered by movement around you
Bothered by noises around you
Bothered by being touched
Abnormal general fatigue
Reduced depth perception
Light sensitivity
Flashes of light
Floaters in field of view
Restricted field of vision
Tunnel vision
"Curtain" billowing into field of view