PERSONAL INJURY DATA SHEET (AUTO ACCIDENT)

Date:_______________________                  Referred by:_________________________

Name:________________________________________SS#:______________________

Date of birth:_____________________

Spouse:_______________________________________SS#:______________________

Street/P.O.Box:___________________________________________________________

City:___________________________State:___________Zip Code:_________________

Telephone(Home):______________________ (Work):___________________________

Employer:___________________________________Supervisor:___________________

Job Title:____________________________________Rate of pay:__________________

Address:________________________________________Phone:__________________

Were you in the scope of your employment when the accident occurred?_____________

Name of your auto insurance company?_______________________________________

Does your auto insurance policy include coverage for the following:

            Uninsured motorist?________ Med/Pay?_________PIP?__________

Private/Group Health Insurance Carrier:_______________________________________

            Have you filed medical bills on health insurance: Yes________ No________

DATE OF ACCIDENT:____________________________________________________

Location:________________________________________________________________

City:__________________________________State:_____________________________

What agency investigated the accident?________________________________________

            Name of investigating officer:_________________________________________

Have you brought us a copy of any accident report? Yes________ No_______

If not, please briefly describe the accident:__________________________________

_______________________________________________________________________

List names and addresses of witnesses to the accident:____________________________

_______________________________________________________________________

_______________________________________________________________________

Owner/Driver of other vehicle:_______________________________________________

Address:_______________________________________________________________

_______________________________________________________________________

Adjuster:____________________________________Phone_______________________

Please list the name (and address, if different from yours) of every person, including yourself, who was injured while in your vehicle in the accident and briefly describe the injuries to each:

_________________________          _________________________________________

                                                            _________________________________________

_________________________          _________________________________________

                                                            _________________________________________

_________________________          _________________________________________

                                                            _________________________________________

If any of the passengers who were injured in your vehicle were minors (under18), please give the name, age and birth of each.

_________________________          ____________            _______________________

_________________________          ____________            _______________________

_________________________          ____________            _______________________

Please list all treatment facilities and/or physicians seen by each person injured:

_________________________          _________________________________________
_________________________          _________________________________________
_________________________          _________________________________________
_________________________          _________________________________________

If you were treated at Keesler Medical Center or at any other military medical facility, please give us the following information:

If you are active/retired military, indicate your branch of service:____________________

If you are a military dependant, indicate the name and social security number of your sponsor, and his/her branch of service:_________________________________________

Have you submitted any medical bills for payment by Blue Cross/Blue Shield?

            Yes_______ No_______

Have you submitted any medical bills for payment by MEDICAID or MEDICARE?

            Yes_______ No_______

If yes, what state?_________________________________________________________

Are you receiving Social Security benefits? Yes________ No________

If yes, what type?_________________________________________________________

If yes, please describe the accident and injury suffered:___________________________

_____________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

PAIN CHART

Please describe your pain by this diagram.

Patient Name: ___________________________________ Date: _____________

PAIN DRAWING Use the symbols below to mark the areas on your body where you feel the following sensations. Include ALL affected areas.

BURNING    NUMBNESS    PINS & NEEDLES    STABBING    ACHES    OTHER

 XXXXXXX    OOOOOOO    ===============    ////////////////////    ^^^^^^    UUUUU

pain line

No pain ||Worst possible pain

The patient with a complaint of back pain fill out a pain drawing using this