1. Dr. R. Mark Pappas
299 Main Street
West Haven, CT 06516
PERSONAL INJURY QUESTIONNAIRE
*****Please provide this office with a copy of the accident report and
your declaration page of your motor vehicle insurance.*****
Name: _______________________
Date of Injury: _____________
Your Ins. Co. _________________ Policy # ________ Agent’s Name _____________
Driver/Other Vehicle: __________________ Ins. Co. ____________ Policy ________
Have you retained an attorney? Yes__ No__
Name ___________
Were there any witnesses?
Names _________________________
Yes__ No__
Phone_______
Nature of the Accident: Were you? Driver__ Front__ or Back__ Seat Passenger
Number of people in your vehicle? ________
Other vehicle: ___________
What direction were you headed? North__ East__ South__
of the street ____________________________________.
West__ on the name
What direction was the other vehicle headed? North__ East__ South__ West__ on
the name of the street ____________________________________.
Were you struck from:
behind__
front__
No__
left side__
right side__
Were you knocked unconscious?
Yes__
If so, for how long? _______
Were police notified? Yes__ No__
In your own words, describe the accident below
_____________________________________________________________________
_____________________________________________________________________
Did you have any physical complaints BEFORE the accident? No__ Yes__ ...If so,
please describe in detail: ________________________________________________
_____________________________________________________________________

2. Please describe how you felt:
During the accident: _____________________________________________________
Immediately After the Accident: ____________________________________________
Later that day: _________________________________________________________
The Next day: __________________________________________________________
Were you provided emergency medical attention following the accident? Yes__ No__
If yes, where?
_____________________________________________________________________
Have you been treated by another doctor since the accident?
Yes__ No__
If yes, please list the doctor’s name and address.
_____________________________________________________________________
What type of treatment did you receive? _____________________________________
Do you have any previous illnesses which relate to this case?
Yes__ No__
If yes, please describe,
_____________________________________________________________________
_____________________________________________________________________
Have you had ever been involved in an accident BEFORE?
Yes__ No__
If yes, please describe including date and types of accident (s), as well as injuries
received. If you received a permanency from any of these accidents, please include this
information as well.
_____________________________________________________________________
_____________________________________________________________________
Since this injury occurred are the symptoms: Improving__ Getting Worse__ Same__
Have you lost time from work as a result of this accident?
Yes__ No__
Last Day Worked: ______________ Type of Employment: ______________________
Are you being compensated for time lost from work?
Yes__ No__
If yes, please state the type of compensation you are receiving:
_____________________________________________________________________
Did you notice any activity restrictions as a result of this injury?
Yes__ No__
If yes, please describe in detail:
_____________________________________________________________________
_____________________________________________________________________

3. PRESENT COMPLAINTS
( ) Headache
( ) Pins and Needles in arms/ legs
( ) Anxiety
( ) Head Seems Too heavy
( ) Numbness in fingers, arms legs
( ) Extreme Fatigue
( ) Head & shoulders tired & heavy
( ) Chest Pain
( ) Insomnia
( ) Mental Dullness
( ) Shortness of Breath
( ) Neuritis
( ) Loss of Memory
( ) Eye Strain
( ) Face Flushed
( ) Equilibrium Problems
( ) Pain behind the Eyes
( ) Face Pale
( ) Dizziness
( ) Eyes sensitive to light
( ) Excess Perspiration
( ) Fainting
( ) Eyes Loss of Focus
( ) Digestive Disorder
( ) Tremors
( ) Double Vision
( ) Nausea, Vomiting
( ) Palpitation
( ) Ears Buzzing/ringing
( ) Diarrhea
( ) Neck Pain
( ) Loss of Taste
( ) Constipation
( ) Neck Stiffness
( ) Loss of Smell
( ) Depression
( ) Neck Motion Restricted
( ) Sinus Trouble
( ) Swollen
( ) Upper Back Pain/Stiffness
( ) Extreme Nervousness
( ) Feet/Hand Cold
( ) Mid Back Pain/Stiffness
( ) Tension
( ) Low Back Pain/Stiffness
( ) Irritability
_________________________________________
signature
( ) Difficulty in
Prolonged Car Riding
_____ ______ ______
date