H&P

PATIENT QUESTIONNAIRE
Name:
Birth Date:

Month Day Year
Date
Gender:
Accident Date:

Month Day Year
Date
Dominant Hand:

Right Left Both
ACCIDENT DETAILS
1. Type of accident

MVA
Please describe the accident
3. Were you the

Driver Front passenger Back passenger Bicycle rider Pedestrian Not Applicable
4. What was your vehicle?

Automobile Pickup Truck SUV Motorcycle Bicycle
5. What was the other vehicle?

Automobile Pickup Truck SUV Motorcycle Bicycle
6. Where was your vehicle hit?

Front end Rear end Right front Right rear Left front Left rear Right side Left side
7. Were you seatbelted?

Yes No Not Applicable
8. Were you helmeted?

Yes No Not Applicable
9. Did the Airbag deploy?

Yes No Don't Recall
10. Were you injured by the airbag?

Yes No
If yes, describe?
11. Were you braced at the time of the impact?

Yes No Don't Recall
12. Did you hit your head?

Yes No Don't Recall
If yes, where?
13. Did you lose consciousness?

Yes No Don't Recall
14. Did you recall the impact?

Yes No Don't Partially
15. Were you dazed or stunned?

Yes No Don't Recall
Describe:
16. Did you have these symptoms?

Dizziness Nausea Vomiting Vision Changes Trouble Speaking Confusion
17. Were you in immediate pain?

Yes No Don't Recall
Where:
If not, when did you notice pain?
18. Describe your injuries:
19. Did you have any cuts?

Yes No
If yes, describe:
20. Did you notice ringing in your ears immediately?

Yes No
If yes, describe:
21. Were you deafened by the sound of the impact?

Yes No
If yes, describe:
HOSPITAL/ER
1. Did you go to the ER?

Yes No
Which hospital?
2. How were you transported?

Ambulance Drove self Spouse Family member Friend Airlift
3. How soon after the accident did you go to the hospital?
4. Were you admitted to the hospital overnight?

Yes No
For how long?
HOSPITAL/ER (CONTINUED)
5. Were X-rays performed in the ER?

Yes No
Details
6. Were CT's performed in the ER?

Yes No
Details:
7. Were MRI's performed in the ER?

Yes No
Details:
8. What treatments/discharge instructions did you receive?

Medication Cane Told to apply heat Surgery Crutches Told to apply ice Cast Told to rest Bandaging Cervical collar Back brace Stitches Arm sling
OTHER TREATING DOCTORS AFTER THE ER
1. Doctor's Name/Speciality:
Diagnostic Testing:

MRI CT X-rays Other
Treatments Received:

Chiropractic Massage Physical Therapy Ultrasound Electrical Stim Medications Injections Therapy
Benefit from treatment:

Partial Complete None
2. Doctor's Name/Speciality:
Diagnostic Testing:

MRI CT X-rays Other
Treatments Received:

Chiropractic Massage Physical Therapy Ultrasound Electrical Stim Medications Injections Therapy
Benefit from treatment:

Partial Complete None
3. Doctor's Name/Speciality:
Diagnostic Testing:

MRI CT X-rays Other
Treatments Received:

Chiropractic Massage Physical Therapy Ultrasound Electrical Stim Medications Injections Therapy
Benefit from treatment:

Partial Complete None
4. Doctor's Name/Speciality:
Diagnostic Testing:

MRI CT X-rays Other
Treatments Received:

Chiropractic Massage Physical Therapy Ultrasound Electrical Stim Medications Injections Therapy
Benefit from treatment:

Partial Complete None
CURRENT STATUS OF SYMPTOMS
Since the accident symptoms are:

Completely Recovered A Lot Better Worse A Little Better Unchanged
NERVOUSNESS
1. Are you nervous about driving?

Yes No Constantly Occasionally
How often?
2. Do you have nightmares?

Yes No Constantly Occasionally
How often?
3. Do you have flashbacks?

Yes No Constantly Occasionally
How often?
4. Do you have intrusive thoughts?

Yes No Constantly Occasionally
How often?
5. Do you have avoidance behavior?

Yes No Constantly Occasionally
How often?
6. Are you easily startled?

Yes No Constantly Occasionally
How often?
7. Do you have panic attacks?

Yes No Constantly Occasionally
How often?
8. Do you have suicidal thoughts?

Yes No Constantly Occasionally
How often?
HEADACHES
1. Have you experienced headaches since the accident?

Yes No Constantly Occasionally
How often?
2. How severe are the headaches?

Mild Moderate Severe Mild-Moderate Moderate-Severe Incapacitating
3. How bad is the pain? (Level 10 being the highest)

1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10
Range _____/10
4. Where is the pain located?

Front of head Behind Eyes Right Temple Hatband region Right side of head Left Temple All over Left side of head Both Temples
5. Are the headaches preceded by vision loss, weakness or numbness?

Yes No
If yes, describe:
6. Describe headache quality

Throbbing Tension Shooting Pressure Sharp
7. Are Headaches accompanied by:
a) Sparkles in vision?

Yes No Constantly Occasionally
b) Sensitivity to light?

Yes No Constantly Occasionally
c) Sensitivity to sound?

Yes No Constantly Occasionally
d) Nausea?

Yes No Constantly Occasionally
e) Vomiting?

Yes No Constantly Occasionally
f) Dizziness?

Yes No Constantly Occasionally
g) Blurred vision?

Yes No Constantly Occasionally
8. What relieves the headaches?

Nothing Medication Ice Rest Darkness
9. How long do the headaches last?
JAW PAIN
1. Have you experienced jaw pain since the accident?

Yes No Constantly Occasionally
How often?
2. Have you experienced:

Pain when chewing Popping Clicking Locking
3. What relieves the pain?

Nothing Medication Soft diet Splint
JOINT PAIN
1. Have you experienced joint pain since the accident?

Yes No Constantly Occasionally
How often?
2. How bad is the pain? (Level 10 being the highest)

1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10
Range _____/10
3. Where is the pain located?

Right shoulder Left shoulder Right elbow Left elbow Right wrist Left wrist Right hand Left hand Right hip Left hip Right knee Left knee Right ankle Left ankle Right foot Left foot
4. Is there limitation of motion?

Yes No
5. What makes it worse?

Range of motion Weight bearing Standing Sitting Bending Lying on side Activities of daily living
6. What makes it better?

Nothing Rest Medication Injections Chiropractic therapy Physical Therapy Heat Ice
NECK PAIN
1. Have you experienced neck pain since the accident?

Yes No Constantly Occasionally
How often?
2. How bad is the pain? (Level 10 being the highest) *

1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10
Range _____/10
3. Where does the pain radiate?

Right shoulder Left shoulder Right arm Left arm Right hand Left hand
4. Where is the numbness/tingling located?

Right shoulder Left shoulder Right arm Left arm Right hand Left hand Intermittent Constant
5. Where is the weakness located?

Right shoulder Left shoulder Right arm Left arm Right hand Left hand Intermittent Constant
6. What makes it worse?

Nothing Range of motion Overhead reaching Weight bearing Standing Sitting Bending Lying on side Activities of daily living
7. What makes it better?

Nothing Rest Medication Injections Chiropractic therapy Physical Therapy Heat Ice Stretching Traction
MID BACK PAIN
1. Have you experienced mid-back pain since the accident?

Yes No Constantly Occasionally
How often?
2. How bad is the pain? (Level 10 being the highest)

1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10
Range (_____/10)
3. Where does the pain radiate?

No Across ribcage Across shoulder blades Around waist
4. Where is the numbness/tingling located?

No Right ribcage Left ribcage Right flank Left flank
5. What makes it worse?

Nothing Range of motion Overhead reaching Weight bearing Standing Sitting Bending Lying on side Activities of daily living
6. What makes it better?

Nothing Rest Medication Injections Chiropractic therapy Physical Therapy Heat Ice Stretching Traction
LOW BACK PAIN
1. Have you experienced low back pain since the accident?

Yes No Constantly Occasionally
How often?
2. How bad is the pain? (Level 10 being the highest)

1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10
Range (_____/10)
3. Where does the pain radiate?

Right buttock Left buttock Right leg Left leg Right foot Left foot
4. Where is the numbness/tingling located?

Right buttock Left buttock Right leg Left leg Right foot Left foot Intermittent Constant
5. Where is the weakness located?

Right buttock Left buttock Right leg Left leg Right foot Left foot Intermittent Constant
6. What makes it worse?

Nothing Range of motion Overhead reaching Weight bearing Standing Sitting Bending Lying on side Activities of daily living
7. What makes it better?

Nothing Rest Medication Injections Chiropractic therapy Physical Therapy Heat Ice Stretching Traction
BOWEL BLADDER SYMPTOMS
Have you noticed loss of bowel or bladder control since the accident?

Yes No Constantly Occasionally
How often?
Incomplete Voiding

Incomplete Voiding
Urgency

Urgency
Please describe:
SEXUAL DYSFUNCTION
Have you noticed sexual problems since the accident?

Yes No Constantly Occasionally
Loss of desire

Loss of desire
Difficulty with arousal

Difficulty with arousal
Difficulty achieving orgasm

Difficulty achieving orgasm
DIZZINESS
1. Have you had dizziness since the accident?

Yes No Constantly Occasionally
How often?
2. Have you had lightheadedness since the accident?

Yes No Constantly Occasionally
How often?
3. Have you felt the room spin?

Yes No Constantly Occasionally
How often?
4. Have you felt off balance?

Yes No Constantly Occasionally
How often?
5. Do you feel off balance only with headaches? If yes, how often:
6. How long does the dizziness last? Duration:
7. Dizziness is accompanied by:

No other symptoms Excessive sweating Anxiety Heart palpitations Ringing of ears
8. What triggers the dizziness?

Quick movements Standing suddenly Driving Loud noises Rolling over Stress
SEIZURES
1. Have you had any seizures since the accident?

Yes No
If yes, how often?
2. How many seizures have you had?

1 2 3 4 5+
3. Please describe the seizure:

Loss of consciousness Automatic repetitive movements Staring spells Involuntary shaking/jerking
4. Any prior history of seizures?

Yes No
5. What did you feel before the seizure(s)?

Nothing Feeling faint Excess sweating Aura perception Nausea Chest pain
Aura Description:
6. What accompanied the seizure(s)?

Bowel incontinence Tongue biting Bladder incontinence Self injury Loss of awareness No loss of awareness Nothing
7. Were the seizure(s) followed by a period of confusion?

Yes No
How long did the confusion last?
HEARING LOSS
1. Have you had hearing loss since the accident?

Right Left Constantly Occasionally No
How often?
2. Is your hearing muffled?

Right Left Constantly Occasionally No
How often?
3. Have you had ringing in the ears?

Right Left Constantly Occasionally No
How often?
4. Have you had ear pain?

Right Left Constantly Occasionally No
How often?
MEMORY LOSS
1. Have you had memory loss since the accident?

Yes No Constantly Occasionally
How often?
Have you had any of the following (check all that apply)?

Short-term memory loss Misplaces objects Changes in personality Forgetfulness Impaired concentration Impaired multitasking Get lost in familiar places Have to write things down to remember them Mental instability Impulsiveness Mood swings
MEDICAL HISTORY - Please list all current or past medical conditions - NOT RELATED TO THE INJURY
1. Check any current illnesses:

ADD/ADHD Alzheimer's disease/dementia Anemia Aneurysm Anxiety Arthritis Atrial fibrillation Bipolar disorder Bleeding disorder Brain tumor Cancer Carpal tunnel syndrome Chronic hepatitis Congestive heart failure COPD/Emphysema Deep vein thrombosis Depression Diabetes Drug dependency Epilepsy Fibromyalgia Gastritis GERD Fracture Heart attack Heart disease Hemophilia High cholesterol HIV Hypertension Hyperthyroidism Hypothyroidism Insomnia Irritable bowel syndrome Joint injury Kidney stone Kidney failure Liver failure Migraines/headaches Multiple sclerosis Muscular dystrophy Neuropathy Parkinson's disease Peptic ulcer disease Prior back condition Prior neck condition Psoriasis Scoliosis Sleep apnea Stroke Surgical repair
2. Have you ever been injured in the past?

Yes No Don't Recall
If yes, please give details:
3. *FEMALES ONLY* Are you pregnant or planning pregnancy?

Yes No
Explain:
4. Please list prior surgeries:
ARE YOU ALLERGIC TO ANY MEDICATIONS? Please list all medications:
Pharmacy Phone #:
CURRENT MEDICATIONS - List all medications you are currently taking. Name/How much/How often
FAMILY ILLNESSES -- Check serious illnesses of your immediate family

ADD/ADHD Diabetes mellitus High cholesterol Muscular dystrophy Alzheimer's Epilepsy Hypertension Neuropathy Eye disease (Glaucoma/Cataracts) Inflammatory bowel disease Parkinson's disease Anemia Psychiatric illness Brain aneurysm Hearing loss Kidney failure Rheumatoid arthritis Brain tumor Heart attack Lung disease Scoliosis Cancer Lupus Skin disease Carpal tunnel syndrome Heart disease Migraines/Headaches Stroke Colon polyps Thyroid disease Other:
SOCIAL HISTORY/PAST HISTORY
1. Do you smoke?

Yes No
Amount?
Number of years?
2. Do you drink alcohol?

Yes No
Amount?
3. Marital Status?

Single Married Divorced Widowed
4. Do you have children?

Yes No
If yes, how many children do you have?
5. Any change in exercise habits, hobbies or social activities following the injury? Please explain:
6. Were you employed at the time of the accident?

Yes No
If yes, which type of work?
7. Did you miss any days of work due to this accident/injury?

Yes No
If yes, how many days?
8. Are you currently employed?

Yes No
If yes, which type of work?
9. Check your highest level of education:

GED High school graduate AA or AS degree BA or BS degree Master's Doctorate No degree
Highest grade completed:
Years of college
REVIEW OF SYSTEMS
PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING SYMPTOMS:

Blurred Vision Blindness Double vision Hearing loss Ringing in the ears Temporomandibular Joint Dysfunction Pain Loss of Smell Loss of Taste Difficulty Chewing Difficulty Swallowing Difficulty Speaking Difficulty Reading Memory Loss Headaches Change in Menstrual Cycle Menopause Impaired Sexual Function High Cholesterol Cough Shortness of Breath Chest pain Palpitations High blood pressure Diabetes Stroke Seizures Loss of consciousness Dizziness Loss of Balance Trouble Walking Difficulty Standing Trouble Falling Asleep Trouble Staying Asleep Panic Attacks Feeling Stress Nervousness Loss of Interest in Activities Depression Weight Loss Weight Gain Weakness Numbness or Tingling Joint Pain or Swelling Swelling of the Ankles Skin Rash or Lesions Stomach Pain Heartburn Change in Bowel Habits Loss of Bladder Control Loss of Bowel Control Blood in Sputum Blood in Stools Fever or Chills
Should be Empty: