Automobile Accident Victim Survey
There are some error(s). Please see each marked section below.
This survey is designed to help us make the accident treatment process as comfortable and effective as possible for our future patients and to implement any new procedures. All information given will not be shared or sold to anyone else and will remain the property of Pain Control Institute, Inc. If there is anything that we have not covered in this survey that you would like to add, please feel free to email us that information. Thank you for your time.
1.
How much damage did your vehicle sustain in the accident?
Very Little - Less than $1,000
Very Little - Less than $1,000
Little - $1,000 -1,500
Little - $1,000 -1,500
Moderate - $1,501 - $3,000
Moderate - $1,501 - $3,000
High - $3,001 - $10,000
High - $3,001 - $10,000
Severe $10,001 - Up
Severe $10,001 - Up
2.
Where did your accident occur?
Dallas, Texas
Dallas, Texas
Dallas suburb (i.e. Plano, Richardson)
Dallas suburb (i.e. Plano, Richardson)
State other than Texas
State other than Texas
Other
3.
Where did the other vehicle hit yours?
Rear
Rear
Front
Front
Side
Side
Other
4.
How many people were in your vehicle including you?
One
One
Two
Two
Three
Three
Four
Four
Other
5.
Were you injured?
Yes
Yes
No
No
Not sure
Not sure
6.
If there were others in the vehicle, how many were injured?
50 character(s) left.
7.
How long after the accident did you notice your injury?
Immediately
Immediately
A few hours
A few hours
Days
Days
Weeks
Weeks
I wasn't injured
I wasn't injured
Other
8.
Were you taken to the hospital by ambulance?
Yes
Yes
No
No
Comment:
500 character(s) left.
9.
What type of medical provider did you first visit?
Emergency Room Doctor
Emergency Room Doctor
Family Doctor (MD)
Family Doctor (MD)
Urgent Care Clinic
Urgent Care Clinic
Chiropractor
Chiropractor
I haven't been to anyone
I haven't been to anyone
Other
10.
Rate how satisfied you were with your first medical provider?
Not at all
Not at all
Somewhat
Somewhat
Satisfied
Satisfied
Very Satisfied
Very Satisfied
Comment:
500 character(s) left.
11.
What date did your accident happen? (Please give month, day and year)
50 character(s) left.
12.
Where is your pain?
350 character(s) left.
13.
If you didn't seek medical treatment immediately after the accident, what were your reasons for not doing so?
500 character(s) left.
14.
Are you aware that medical treatment costs may be covered 100% even if you don't have any health insurance and without hiring a lawyer?
Yes
Yes
No
No
15.
What factors are important in choosing a medical provider for ongoing therapy? (check all that apply)
Close to my home
Close to my home
Close to my work
Close to my work
Open after 5PM
Open after 5PM
Open on weekends
Open on weekends
Takes insurance
Takes insurance
Other
16.
Do you have Personal Injury Protection Insurance (PIP) or Medical Payments (MedPay) on your automobile policy?
Yes
Yes
No
No
Not sure
Not sure
17.
What medication are you taking for your pain? (Check all that apply)
Over the counter (i.e. Tylenol, Advil, etc.)
Over the counter (i.e. Tylenol, Advil, etc.)
Prescription pain medication (i.e. Vicodin)
Prescription pain medication (i.e. Vicodin)
Prescription muscle relaxants
Prescription muscle relaxants
Prescription Anti-Inflammatory
Prescription Anti-Inflammatory
I'm not taking any medication
I'm not taking any medication
Other
18.
Check the statements that apply to your condition right now
I feel that my pain is getting better
I feel that my pain is getting better
I feel that my pain is getting worse
I feel that my pain is getting worse
I feel that my condition has not changed since the accident
I feel that my condition has not changed since the accident
Other
19.
If you have been in an accident previously and had treatment, please describe what type of provider you went to (i.e. doctor) and what did you like or didn't like about the experience.
500 character(s) left.
20.
If you didn't know where to go for treatment of your injuries how would you find some place to go? (choose the answer that would be your first choice)
A referral from my family doctor
A referral from my family doctor
A referral from the emergency room
A referral from the emergency room
A friend's recommendation
A friend's recommendation
A television ad
A television ad
A newspaper ad
A newspaper ad
A letter from a clinic I received
A letter from a clinic I received
Searching the internet
Searching the internet
Lawyer referral
Lawyer referral
Other
21.
Concerning lawyers what statements would you consider true?
They are necessary to get my medical bills paid
They are necessary to get my medical bills paid
I won't get any money if I don't hire one
I won't get any money if I don't hire one
I don't trust any of them
I don't trust any of them
I have/ will hire one
I have/ will hire one
I will not hire one
I will not hire one
Thank you for taking time to complete our survey. Please be assured the answers you gave are for internal purposes only and will not be shared with anyone else. If you have any questions that we may be able to answer, please don't hesitate to contact us regarding medical treatment.