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What is the extent of the injury(ies) sustained?
Death of Victim
Amputation or Dismemberment
Paralysis
Hospitalization with Surgery
Lost eye, loss of eyesight, loss or or impaired vision
Brain Injury ("TBI")
Head Trauma
Open head injury
Closed head injury
Loss of consciousness
Upper and/or lower back pain
Slipped, ruptured, or herniated disc(s)
Severe pain-describe in detail later
Bone fractures-describe in detail later
Neck trauma (Whiplash)
Post Accident Anxiety
Tear of muscle, ligament, or tendon
Contusions/Bruises
Multiple injuries-describe in detail later
Other-describe in detail later
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