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Patient infromation
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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1
Name and surname
2
Date of birth
3
Age
4
Home address
5
Telephone numbers
6
Date of accident
7
Accompanied by
8
Previous medical / surgical history
9
Type of accident
Select one or more answers
Pedestrian
Passenger
Driver
Train
Other
10
Injuries sustained
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