Personal Injury History Form Your name Dates and Time of accident Signed by (insert name) I hereby consent to submitting this form electronically and acknowledge that my digital signature serves as confirmation of my acceptance of the terms outlined within this form. Location of Accident Did police come to the scene? Did you go to the hospital? Yes No Is there a police report? Yes No Did you go to the hospital? Yes No If yes, what is the name of the hospital? List any services you recieved: (X-ray, MRI, Etc.) How long did they treat you? Please describe to the best of your knowledge what happened during the accident: What injuries did you receive? Be as specific as possible. Did you lose consciousness after impact? Did you experience a flash of light or an 'explosion' in your head? Yes No Select all relevant symptoms Confused Disoriented Dizzy Nauseated Blurred Vision Ringing/Buzzing Ears Changes in bowel or bladder function Do you still have any of these symptoms? Yes No Are you currently suffering from any of the following? Restlessness Irritable Sleplessness Forgetfulness Difficulty Concentrating Difficulty with Memory Reduced Tolerance to Heat Reduced Tolerance to Alcohol Headache Any other symptoms? Anyone else involved? Do you have an accident injury insurance policy? Yes No Insurance Name Policy # Agent Name Agent Phone # Send
