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What was the date of accident? |
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What time did it occur? |
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How many vehicles were involved in the accident? |
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What was the esitmated damage to the vehicle you were in? |
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What State did the accident occur in? |
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What city did the accident occur in? |
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What intersection or street were you on when the accident occured? |
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What direction were you traveling? |
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What type of impact was the accident? |
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Did your vehicle hit anything after the accident? |
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Where were you sitting in the vehicle during ur accident? |
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Did you know the accident was coming? |
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What type of vehicle were you in? |
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What type of vehicle impacted yours? |
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At the time of the impact, how fast was your vehicle moving? |
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At the time of impact, how fast was the other vehicle moving? |
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During and after the crash what happened to your vehicle? |
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Did you lose consciousness during the accident? |
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How was your head positioned during the accident? |
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How was your torso positioned during the accident? |
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How were your hands positioned during the accident? |
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Did your head hit anything during the accident? |
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Did your face hit anything?(No or Yes , the please describe.) |
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Did your shoulders hit anything during the accident? No or Yes, then please describe |
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Did your neck hit anything during the accident?(No or Yes, then please describe.) |
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Did your chest hit anything during the accident?(No or Yes, then please describe.) |
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Did your hips hit anything during the accident?(No or Yes, then please describe.) |
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Did your knees hit anything during the accident?(No or Yes, then please describe.) |
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Did your feet hit anything during the accident?(No or Yes, then please describe.) |
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What Kind of headrest was in your vehicle? |
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Where was the headrest postioned on your head? |
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Did you have your seatbelt during the accident? |
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What was damaged in your vehicle? (Select all that apply) |
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Choose the items that dented inward? |
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Choose the door that would not open as a result of the accident |
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Did you go to the hosptial? If no, why and do not anwser 38-43 |
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What was the name of the hosptial? |
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How did you get to the hosptial? |
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Were you hosptialized over night? |
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Select what you prescribed at the hosptial |
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Did you recieve any stiches for any cuts at the hospital? |
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Were X rays taken at the hospital? If yes, which are was taken? |
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Enter Verification Characters: |
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