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About Us
Services & Techniques
Conditions Treated
Contact Us
- Appointment Request
Patient Center

(859) 781-8700

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Auto Accident / Work Injury Report

Auto Accident / Work Injury Report

Accident / Work Injury Report

Name*

Email *

Phone *

Date of Accident *

Location of accident*

Time of accident *

Describe how the accident happened in your own words *

Where you unconscious?

Yes No

If yes, how long?

In a daze?

Yes No

Please describe how you felt immediately after the accident

Have you gone to the hospital or seen any other doctor?

Yes No

If yes, how did you get their?

Ambulance Private Transportation

Were you placed in:

Neck collar Splints Brace

When did you go?

Just after accident The next day Other

Other

Name of the hospital

Name of the attending doctor

How long did you stay?

Were X-rays taken?

Yes No

What was the diagnosis?

What treatment did you receive?

What recommendations were made?

Have you been able to work since this injury?

Yes No

Are your work activities restricted?

Yes No

Is your condition getting worse?

Yes No Constant Comes and Goes

Was the accident reported?

No Police Employer/Supervisor

Indicate the symptoms that are a result of this injury:

Dizzines Memory loss Difficulty sleeping Jaw problems Nausea Memory loss Irritability Arm/shoulder pain Back pain Headache(s) Fatigue Numb hands/fingers Lower back pain Blurred vision Tension Chest pain Back stiffness Buzzing in ear Neck pain Shortness of breath Leg pain Ears ringing Neck stiff Stomach upset Numb feet/toes Other

Other

Traffic / Auto Accident

Were you the

Driver Front passenger Rear passenger

Number of people in vehicle:

Was a traffic citation issued?

Yes No

If yes, to whom?

Driver of your vehicle Driver of other vehicle

Did the police come to the accident site?

Yes No

Were their any witnesses?

Yes No

Were you wearing your set belt?

Yes No

Does it have a shoulder harness?

Yes No

Was this vehicle equipped with an air bag?

Yes No

Did it inflate?

Yes No

In relation to the base of your skull, where was the headrest?

Above Below At the base of skull

What did your vehicle impact?

Another vehicle Other

Other

Make and model of vehicle you were occupying

Year

Make and model of other vehicle involved

Year

At the time of impact your vehicle was:

Slowing down Stopped Gaining speed Moving at steady speed

At the time of impact the other vehicle was

Slowing down Stopped Gaining speed Moving at steady speed

Estimated speed at the time of crash: Your vehicle:___mph Other vehicle:___mph

Did any part of your body strike anything in the vehicle?

No Yes

If yes please explain:

Did the impact to your vehicle come from the:

Front Rear Right side Left side Other

Other

During impact were you facing

Right Left Forward Looking in rear view mirror

Were you:

Aware of the collision Surprised

If aware were you:

Relaxed Bracing yourself for the impact

Were you holding on to the steering wheel at the time of impact?

YEs No

Have you been in contact with your auto insurance company?

No Yes

Have you been in contact with your auto insurance company?

Yes No

If yes, Date:

Work / On The Job Injury

Was your accident directly related to your work?

Yes No

What is your job title:

List any equipment, machinery and/or object related to accident:

Type of work being done at the time of injury:

Has a worker comp claim been filed?

Yes No

If yes, Date:

Give the address where the accident occurred: (if other than that of employer)

What recommendations did your employer make just after your accident?

Has this type of accident happened to you before?

Yes No

How long have been employed there:

To the best of your knowledge has this type of accident occurred in your workplace before?

Yes No

Recovery/Job Assessment

To evaluate the effect that continuing work will have on your recovery please complete the following:

How many hours are in a normal work day?

Please indicate your daily job duties and any activities which you are occasionally asked to perform:

Standing Driving Operating equipment Sitting Twisting Work with arms above head Walking Crawling Typing Lifting Bending Stooping Other

Other

Additional Insurance

2^ndInsurance Source or Auto Insurance

Type of Insurance:

Co. Name:

Agent's Name

Phone

Insured's name

Policy #

Claim #

Agent's Name

By submitting this form, I acknowledge that I have read and understood this agreement.

Date

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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Location

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Douglas P Krift DC

Address

1467 S Ft Thomas Ave
Fort Thomas, KY 41075

Contact Information (859) 781-8700

[email protected]

Office Hours

Monday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Tuesday

Closed

Wednesday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Thursday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Friday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Saturday

Closed

Sunday

Closed

1467 S Ft Thomas Ave
Fort Thomas, KY 41075

(859) 781-8700

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