• PATIENT QUESTIONNAIRE

  • Birth Date:
     / /
  • Accident Date:
     / /
  • Dominant Hand:

  • ACCIDENT DETAILS


  • 3. Were you the

  • 4. What was your vehicle?

  • 5. What was the other vehicle?

  • 6. Where was your vehicle hit?

  • 7. Were you seatbelted?
  • 8. Were you helmeted?
  • 9. Did the Airbag deploy?
  • 10. Were you injured by the airbag?
  • 11. Were you braced at the time of the impact?

  • 12. Did you hit your head?

  • 13. Did you lose consciousness?

  • 14. Did you recall the impact?

  • 15. Were you dazed or stunned?

  • 16. Did you have these symptoms?
  • 17. Were you in immediate pain?

  • 19. Did you have any cuts?

  • 20. Did you notice ringing in your ears immediately?

  • 21. Were you deafened by the sound of the impact?

  • HOSPITAL/ER

  • 1. Did you go to the ER?

  • 2. How were you transported?

  • 4. Were you admitted to the hospital overnight?

  • HOSPITAL/ER (CONTINUED)

  • 5. Were X-rays performed in the ER?
  • 6. Were CT's performed in the ER?
  • 7. Were MRI's performed in the ER?
  • 8. What treatments/discharge instructions did you receive?

  • OTHER TREATING DOCTORS AFTER THE ER

  • Diagnostic Testing:

  • Treatments Received:

  • Benefit from treatment:
  • Diagnostic Testing:

  • Treatments Received:

  • Benefit from treatment:
  • Diagnostic Testing:

  • Treatments Received:

  • Benefit from treatment:
  • Diagnostic Testing:

  • Treatments Received:

  • Benefit from treatment:

  • CURRENT STATUS OF SYMPTOMS

  • Since the accident symptoms are:

  • NERVOUSNESS

  • 1. Are you nervous about driving?
  • 2. Do you have nightmares?
  • 3. Do you have flashbacks?
  • 4. Do you have intrusive thoughts?
  • 5. Do you have avoidance behavior?
  • 6. Are you easily startled?
  • 7. Do you have panic attacks?
  • 8. Do you have suicidal thoughts?

  • HEADACHES

  • 1. Have you experienced headaches since the accident?
  • 2. How severe are the headaches?
  • 3. How bad is the pain? (Level 10 being the highest)
  • 4. Where is the pain located?

  • 5. Are the headaches preceded by vision loss, weakness or numbness?
  • 6. Describe headache quality

  • 7. Are Headaches accompanied by:

  • a) Sparkles in vision?
  • b) Sensitivity to light?
  • c) Sensitivity to sound?
  • d) Nausea?
  • e) Vomiting?
  • f) Dizziness?
  • g) Blurred vision?
  • 8. What relieves the headaches?

  • JAW PAIN

  • 1. Have you experienced jaw pain since the accident?
  • 2. Have you experienced:

  • 3. What relieves the pain?

  • JOINT PAIN

  • 1. Have you experienced joint pain since the accident?
  • 2. How bad is the pain? (Level 10 being the highest)
  • 3. Where is the pain located?

  • 4. Is there limitation of motion?
  • 5. What makes it worse?

  • 6. What makes it better?

  • NECK PAIN

  • 1. Have you experienced neck pain since the accident?
  • 2. How bad is the pain? (Level 10 being the highest)*
  • 3. Where does the pain radiate?
  • 4. Where is the numbness/tingling located?
  • 5. Where is the weakness located?
  • 6. What makes it worse?

  • 7. What makes it better?

  • MID BACK PAIN

  • 1. Have you experienced mid-back pain since the accident?
  • 2. How bad is the pain? (Level 10 being the highest)
  • 3. Where does the pain radiate?

  • 4. Where is the numbness/tingling located?

  • 5. What makes it worse?

  • 6. What makes it better?

  • LOW BACK PAIN

  • 1. Have you experienced low back pain since the accident?
  • 2. How bad is the pain? (Level 10 being the highest)
  • 3. Where does the pain radiate?
  • 4. Where is the numbness/tingling located?
  • 5. Where is the weakness located?
  • 6. What makes it worse?

  • 7. What makes it better?

  • BOWEL BLADDER SYMPTOMS

  • Have you noticed loss of bowel or bladder control since the accident?

  • SEXUAL DYSFUNCTION

  • Have you noticed sexual problems since the accident?

  • DIZZINESS

  • 1. Have you had dizziness since the accident?
  • 2. Have you had lightheadedness since the accident?
  • 3. Have you felt the room spin?
  • 4. Have you felt off balance?
  • 7. Dizziness is accompanied by:

  • 8. What triggers the dizziness?

  • SEIZURES

  • 1. Have you had any seizures since the accident?
  • 2. How many seizures have you had?
  • 3. Please describe the seizure:

  • 4. Any prior history of seizures?

  • 5. What did you feel before the seizure(s)?
  • 6. What accompanied the seizure(s)?

  • 7. Were the seizure(s) followed by a period of confusion?

  • HEARING LOSS

  • 1. Have you had hearing loss since the accident?
  • 2. Is your hearing muffled?
  • 3. Have you had ringing in the ears?
  • 4. Have you had ear pain?

  • MEMORY LOSS

  • 1. Have you had memory loss since the accident?
  • Have you had any of the following (check all that apply)?

  • MEDICAL HISTORY - Please list all current or past medical conditions - NOT RELATED TO THE INJURY

  • 1. Check any current illnesses:
  • 2. Have you ever been injured in the past?
  • 3. *FEMALES ONLY* Are you pregnant or planning pregnancy?
  • FAMILY ILLNESSES -- Check serious illnesses of your immediate family

  • SOCIAL HISTORY/PAST HISTORY

  • 1. Do you smoke?
  • 2. Do you drink alcohol?
  • 3. Marital Status?
  • 4. Do you have children?
  • 6. Were you employed at the time of the accident?
  • 7. Did you miss any days of work due to this accident/injury?
  • 8. Are you currently employed?
  • 9. Check your highest level of education:

  • REVIEW OF SYSTEMS

  • PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING SYMPTOMS:
  • Should be Empty: