What type of accident were you in?
How long ago was it?
Very Recently
Past 90 Days
Past Year
More than 1 year ago
Were you injured?
Did you receive emergency medical treatment immediately following the accident?
(i.e. at the scene)
Did you receive further medical treatment in the time following the accident because of this accident?
(i.e. with your family doctor)
Rate your pain on a scale of 1–10
(10 being the most severe pain)
Rate the disruption to your life on a scale of 1–10
(10 being completely disrupted)
Have you been offered an insurance settlement?
Was a police report filed?
