Brain Injury

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Accident Information

1. Did you injure your head or face in the accident?

   Yes No

     If yes, please describe:

2. Did you lose consciousness?

	Not at all	Yes, 1 hour to 3 days
	Yes, 1 hour or less	Yes, more than 3 days *
* If loss of consciousness lasted more than 3 days (72 hours), skip to item 4.

3. Below is a list of symptoms that usually occur within minutes, hours, or days after a head injury. Please indicate whether you had any of the following after the accident. Check all that apply.

		Headaches		Vision problems
		Whiplash, neck pain		Drowsiness
		Dizziness		Ringing in ears, hearing problems
		Memory loss, amnesia		Nausea or vomiting

4. Below is a list of symptoms that commonly occur weeks or months after a head injury. Please Indicate whether you had any of the following after the accident. Check all that apply.

		Headaches		Nightmares
		Misplace things		Forget what you have read
		Dizziness		Feel frustrated
		Lose train of thought		Forget names or phone numbers
		Feel tired		Impatience
		Think Slowly		Trouble following instructions
		Move slowly		Irritability or short temper
		Poor concentration		Trouble following conversations
		Trouble falling asleep		Feel sad or blue
		Forget if you have done things		Trouble coming up with the right word

Please describe any additional information in the space below:

Contact Information

* Your Name:		Mr. Mrs. Ms. Dr.
Marital Status:		Single Married Divorced Separated Widowed
* Address:
* City:
County:
* State:
* Zip:
* Home Phone:
Work Phone:
Cell Phone:
* E-mail:
* SPAM CHECK:		Please tye the numbers 1, 2, and 3 in the field above using no commas and no spaces

Please review your information before sending.

The Joel Bieber Firm, Virginia personal injury lawyers serving Richmond, Petersburg, Williamsburg, Newport News, Hampton, Chesapeake, Norfolk and Virginia Beach. Our South Carolina personal injury lawyers are located in Greenville. Our firm also includes North Carolina personal injury lawyers.