Car Accident Diary Form

Use this car accident diary form to record important information related to the accident, your injuries, and your recovery.

If you're making a claim for injury related to a car accident, use this form to record important information related to the accident, your injuries, and your recovery. You can either print out this form and fill it out by hand, or use it as a guide or checklist of the types of things that you should document, and then follow 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

â Doctors, specialists, and other health care providers seen

â Treatments/tests received and performed

â Medical expenses incurred and paid ($ amount)

â Medications prescribed and taken

Lost Income

â Days/hours of work missed

â Other lost income

Pain & Suffering

PHYSICAL PAIN

Location(s)

â Head

â Neck

â Lower back

â Shoulder, arm, wrist

â Leg, knee, foot

â Other

Severity

â Mild

â Moderate

â Severe

Type of pain

â Sharp

â Aching

â Soreness

â Shooting pain

â Stabbing pain

â Spasm

â Numbness

â Tingling

â Stiffness

Explain (including activities that lead to an increase in pain and treatments or methods that help to alleviate pain)

EMOTIONAL DISTRESS

Symptoms

â Sleep disrupted

â Appetite lost or diminished

â Stress and anxiety

â Embarrassment

â Depression

â Strained family relationships

â Other

Explain

MISSED OPPORTUNITIES AND OTHER EFFECTS ON YOUR LIFE

â Recreational activities

â Vacation

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

â Other effects

Explain

Evidence

â Photos

â Medical records and bills (including prescriptions)

â Other

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