| Name | Description | Type | Additional information |
|---|---|---|---|
| NameOfInjury | string |
None. |
|
| DateOfInjury | date |
None. |
|
| TimeOfInjury | date |
None. |
|
| PlaceOfInjury | string |
None. |
|
| IncidentOfInjury | string |
None. |
|
| PhysicianDetails | PersonalDetails |
None. |
|
| DeatilsOfTreatmentReceivedDoctorsAndHospitals | string |
None. |
|
| InPatientDates | string |
None. |
|
| IsEmergencyCompanyContacted | boolean |
None. |
|
| ReasonForNotContacting | string |
None. |
|
| IsPregnant | boolean |
None. |
|
| PregnancyWeeks | integer |
None. |
|
| HasPreviousHistoryOfIllness | boolean |
None. |
|
| HistoryOfIllnessDescription | string |
None. |
|
| HasPrivateInsurance | boolean |
None. |
|
| PrivateInsuranceCarrierDetails | string |
None. |
|
| HasEHIC | boolean |
None. |
|
| IsEHICPresented | boolean |
None. |