Car Accident Diary Form

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To keep track of everything related to your case, use this form. You can either print it out and add it to your paper diary (filling it out when you want to make an entry) or use the form as a guide or checklist of the types of things that you should document, and then make an entry following your own format.

To learn more about how to keep a diary about your case -- and how it can help -- check out Keep a Car Accident Diary to Protect Your Claim.

Date

Time

(Fill in the sections that apply)

Medical Treatment and Bills

❏ Doctors and other health care providers seen

❏ Treatments/Tests received

❏ Medical Expenses incurred

❏ Medications taken

Lost Income

❏ Hours of work missed

❏ Other lost income

Pain & Suffering

PHYSICAL PAIN

Location(s)

❏ Head

❏ Neck

❏ Low Back

❏ Shoulder, arm, wrist

❏ Leg, knee, foot

❏ Other

Severity

❏ Mild

❏ Moderate

❏ Severe

Type of pain

❏ Sharp

❏ Aching

❏ Soreness

❏ Shooting pain

❏ Stabbing pain

❏ Spasm

❏ Numbness

❏ Tingling

❏ Stiffness

Explain (including such things as what activities caused the pain and what activities made it better)

EMOTIONAL DISTRESS

Symptoms

❏ Sleep disturbed

❏ Eating difficulty

❏ Stress

❏ Embarrassment

❏ Depression

❏ Strained family relationships

❏ Other

Explain

MISSED OPPORTUNITIES AND OTHER EFFECTS ON YOUR LIFE

❏ Recreational activities

❏ Vacation

❏ Special Events (birthdays, weddings, graduations, funerals, etc.)

❏ Other effects

Explain

Evidence

❏ Photos

❏ Medical bills (including prescriptions)

❏ Disability Certificates (by doctor, authorizing missed work)

❏ Other

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