• MVA, VA, Other Incident: Complaints & ADL

    You have been directed to this additional form because you have indicated that you had been involved in an accident.

  • Basic Information

  • Have you been to DREAM Wellness prior to today for this complaint?*

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  • Date of Birth*
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  • Date of Injury/Onset:
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  • Dominant Hand*
  • Are your current complaints the result of an automobile accident?*

  • Automobile Accident Details and Description

  • Your Vehicle Type:*

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  • Damage to your vehicle*
  • What was your vehicle doing at time of accident?*

  • Visibility at the time of accident:*
  • Road conditions at time of accident: (Choose all that apply)*

  • Point of Impact: (Choose all that apply)*

  • Who hit who/what?*

  • During the Accident:

  • Did you see the accident coming?*
  • Were you braced for the impact?*
  • Were you wearing a shoulder/lap seat belt?*
  • Did the driver's front airbag deploy?*
  • Did passenger front airbag deploy?*
  • Did any side airbags deploy?*
  • Your headrest position?*

  • What was the direction of your head at the time of impact?*

  • Did your body strike the inside of your vehicle?*
  • Did you lose consciousness during the injury?*
  • Damage to other vehicle if applicable:
  • Did police show up at the scene?*
  • Was an accident report filled out?*
  • Where did you go immediately from the scene of the accident?*

  • How did you get there?*

  • Since the accident, have X-Rays been taken?*
  • Since the accident, was lab work done?*
  • Following the accident, were you given...

  • Check any of the symptoms you experienced right after and/or within a few days following the accident*

  • Historical Information

  • Prior Similar Symptoms:

  • Has your history contributed to your symptoms?

  • Have you seen any other healthcare providers for this complaint prior to visiting DREAM Wellness?*

  • Prior Care / Treatment for this complaint

    If you have seen other healthcare providers for this complaint, enter the information below:

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  • Today's Date (Date of follow up visit)*
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  • Location of pain today (check all that apply)*

  • Are your headaches on the... (check all that apply)*
  • How would you describe the headaches? (Choose all that apply)*

  • Headache Frequency*
  • Rows
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  • Heachace Intensity*
  • How would you describe the jaw pain? (Choose all that apply)*

  • Jaw Pain Frequency*
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  • Jaw Pain Intensity*
  • Which eye hurts?*
  • How would you describe the eye pain? (Choose all that apply)*

  • Eye Pain Frequency*
  • Rows
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  • Eye Pain Intensity*
  • Where does your neck hurt? (Choose all that apply)*

  • How would you describe the neck pain? (Choose all that apply)*

  • Neck Pain Frequency*
  • Rows
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  • Neck Pain Intensity*
  • Does your upper back hurt on the... (check all that apply)*

  • How would you describe the upper back pain? (Choose all that apply)*

  • Upper Back Pain Frequency*
  • Rows
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  • Upper Back Pain Intensity*
  • Does your mid back hurt on the... (check all that apply)*

  • How would you describe the mid back pain? (Choose all that apply)*

  • Mid Back Pain Frequency*
  • Rows
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  • Mid Back Pain Intensity*
  • Does your low back hurt on the... (check all that apply)*

  • How would you describe the low back pain? (Choose all that apply)*

  • Low Back Pain Frequency*
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  • Low Back Pain Intensity*
  • Where does your chest hurt... (check all that apply)*

  • How would you describe the chest pain? (Choose all that apply)*

  • Chest Pain Frequency*
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  • Chest Pain Intensity*
  • How would you describe the abdominal pain? (Choose all that apply)*

  • Abdominal Pain Frequency*
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  • Abdominal Pain Intensity*
  • How would you describe the rib pain? (Choose all that apply)*

  • Rib Pain Frequency*
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  • Rib Pain Intensity*
  • Does your buttocks hurt on the... (check all that apply)*

  • How would you describe the buttocks pain? (Choose all that apply)*

  • Buttocks Pain Frequency*
  • Rows
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  • Buttocks Pain Intensity*
  • Which shoulder hurts? (Check all that apply)*

  • How would you describe the shoulder pain? (Choose all that apply)*

  • Shoulder Pain Frequency*
  • Rows
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  • Shoulder Pain Intensity*
  • Which upper arm hurts? (Check all that apply)*

  • How would you describe the upper arm pain? (Choose all that apply)*

  • Upper Arm Pain Frequency*
  • Rows
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  • Upper Arm Pain Intensity*
  • Which hand hurts? (Check all that apply)*

  • How would you describe the hand pain? (Choose all that apply)*

  • Hand Pain Frequency*
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  • Hand Pain Intensity*
  • Which wrist hurts? (Check all that apply)*

  • How would you describe the wrist pain? (Choose all that apply)*

  • Wrist Pain Frequency*
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  • Wrist Pain Intensity*
  • Which hip hurts? (Check all that apply)*

  • How would you describe the hip pain? (Choose all that apply)*

  • Hip Pain Frequency*
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  • Hip Pain Intensity*
  • Which leg hurts? (Check all that apply)*

  • How would you describe the leg pain? (Choose all that apply)*

  • Leg Pain Frequency*
  • Rows
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  • Leg Pain Intensity*
  • Which knee hurts? (Check all that apply)*

  • How would you describe the knee pain? (Choose all that apply)*

  • Knee Pain Frequency*
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  • Knee Pain Intensity*
  • Which foot hurts? (Check all that apply)*

  • How would you describe the foot pain? (Choose all that apply)*

  • Foot Pain Frequency*
  • Rows
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  • Foot Pain Intensity*
  • Which side if applicable? (Check all that apply)*

  • How would you describe the pain? (Choose all that apply)*

  • Pain Frequency*
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  • Pain Intensity*
  • Which forearm hurts? (Check all that apply)*

  • How would you describe the forearm pain? (Choose all that apply)*

  • Forearm Pain Frequency*
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  • Forearm Pain Intensity*
  • Is today's visit a routine visit or examination (first exam or re-exam)?*

  • Activites of Daily Living

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