100 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.com
Automobile Accident History
First Name
Last Name
Birthdate
Date of Accident
Time Accident Occurred
H M
Were you taken to the hospital?
Did you stay in the hospital as a patient?
Name of the doctor who treated you after the accident?
Were X-rays taken at that time?
Which X-rays were taken?

The following questions pertain to you, the patient, and the vehicle you were in.
Were you unable to work/attend school due to your injuries?
From:
To:
Have you retained an attorney?
100 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.com
What type of accident was this?
Where were you seated in the vehicle?
Was the trunk of your body pointed straightforward on impact?
Was your head pointed straightforward on impact?
What were you doing at the time of impact?
Were you aware of the approaching collision prior to impact?
Did you lose consciousness?
How far is the top of the headrest from the top of your head?
Inches
Were you wearing a seat belt?
Type of seat belt?
Were airbags engaged?
100 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.com
On which part of the vehicle did the following body part(s) hit?
What type of clothing were you wearing?
Were the vehicle seats leather or cloth?
Were you on the job at the time of injury?
Was a report filed with your employer?

100 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.com
Please specify the following details regarding the vehicle:
Was the vehicle moving upon impact?
Was the driver's foot on the brake?
Was the vehicle:

The following questions pertain to the other vehicle involved in the accident:
Please specify the following details regarding the other vehicle:
Was the other vehicle moving upon impact?
Was the other driver or any passengers injured?
100 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.com
Please give us your automobile insurance information or driver of vehicle, if you were a passenger:
Who was at fault?
Company Name
Name of Insured
Claim Mailing Address
Claim No.
Claim Ph.
Do you carry Med Pay or PIP Coverage?
Does your policy have uninsured coverage?
Have you accepted any settlement?
Has either insurance tried to settle the claim?

Please give us other involved parties' automobile insurance information:
Company Name
Name of Insured
Address
Claim No.
Claim Ph.

100 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.com
Patient Description of Automobile Accident
Explain in your own words exactly how this accident occurred; what you felt as it happened, and how you have felt since. It is important that you describe all activities related to this accident including any emergency help such as paramedics, police, bystanders, etc., that may have assisted. Please use details and be specific, as no fact is too small to mention.
Signature
Today's Date: 20 Aug 2017