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Edmonton
Sherwood Park
Accident Form
"
*
" indicates required fields
Your Information
Name
*
First Name *
Last Name *
Email Address
*
HISTORY OF ACCIDENT
1.
Date of accident
Date of accident
DD dash MM dash YYYY
2.
Address/location of accident
Address/location of accident
3.
Were you...
Were you...
A passenger in a vehicle?
The driver of a vehicle?
A pedestrian?
At work?
Other
Please specify...
4.
What type/model of vehicle?
What type/model of vehicle?
5.
Estimated damage
Estimated damage
Please enter a number greater than or equal to
0
.
6.
Were you wearing a seatbelt?
Were you wearing a seatbelt?
Yes
No
7.
Where was the vehicle hit?
Where was the vehicle hit?
Front end
Rear end
Front right area
Front left area
Rear right area
Rear left area
Head on
On driver's side
On passenger's side
Other
Please enter where the vehicle was hit
8.
Was there any direct trauma?
Was there any direct trauma?
Yes
No
Did your...
Did your...
Forehead
Face
Chin
Side of head
Back of head
Top of head
Teeth Jaw
Other
Please specify
forcibly strike...
forcibly strike...
Steering wheel
Windshield
Passenger's side window
Driver's side window
Headrest
Seat
Roof
Interior of car
Other
Please specify
9.
Were any areas of your body painful shortly after the accident/incident?
Were any areas of your body painful shortly after the accident/incident?
Head
Neck
Face
Jaw
Left shoulder
Right Shoulder
Left arm
Right arm
Lower back
Upper back
Other
Please specify
10.
Briefly describe the history of symptoms, accident or incident
Briefly describe the history of symptoms, accident or incident
11.
Did you go to the hospital?
Did you go to the hospital?
Yes
No
How did you get to the hospital?
How did you get to the hospital?
By car
By ambulance
Other
12.
Has a doctor or dentist ever diagnosed a TMJ disorder prior to the accident?
Has a doctor or dentist ever diagnosed a TMJ disorder prior to the accident?
Yes
No
Please explain
13.
What treatment have you received to date?
What treatment have you received to date?
Meds
Physio
Chiro
Patient Signature
Signature
*
Parent/Guardian if patient is under 18
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