H&P

PATIENT QUESTIONNAIRE
Name:
Birth Date:

MonthDay Year
Date
Gender:
Accident Date:

MonthDay Year
Date
Dominant Hand:

RightLeftBoth
ACCIDENT DETAILS
1. Type of accident

MVA
Please describe the accident
3. Were you the

DriverFront passengerBack passengerBicycle riderPedestrianNot Applicable
4. What was your vehicle?

AutomobilePickup TruckSUVMotorcycleBicycle
5. What was the other vehicle?

AutomobilePickup TruckSUVMotorcycleBicycle
6. Where was your vehicle hit?

Front endRear endRight frontRight rearLeft frontLeft rearRight sideLeft side
7. Were you seatbelted?

YesNoNot Applicable
8. Were you helmeted?

YesNoNot Applicable
9. Did the Airbag deploy?

YesNoDon't Recall
10. Were you injured by the airbag?

YesNo
If yes, describe?
11. Were you braced at the time of the impact?

YesNoDon't Recall
12. Did you hit your head?

YesNoDon't Recall
If yes, where?
13. Did you lose consciousness?

YesNoDon't Recall
14. Did you recall the impact?

YesNoDon't Partially
15. Were you dazed or stunned?

YesNoDon't Recall
Describe:
16. Did you have these symptoms?

DizzinessNauseaVomitingVision ChangesTrouble SpeakingConfusion
17. Were you in immediate pain?

YesNoDon't Recall
Where:
If not, when did you notice pain?
18. Describe your injuries:
19. Did you have any cuts?

YesNo
If yes, describe:
20. Did you notice ringing in your ears immediately?

YesNo
If yes, describe:
21. Were you deafened by the sound of the impact?

YesNo
If yes, describe:
HOSPITAL/ER
1. Did you go to the ER?

YesNo
Which hospital?
2. How were you transported?

AmbulanceDrove selfSpouseFamily memberFriendAirlift
3. How soon after the accident did you go to the hospital?
4. Were you admitted to the hospital overnight?

YesNo
For how long?
HOSPITAL/ER (CONTINUED)
5. Were X-rays performed in the ER?

YesNo
Details
6. Were CT's performed in the ER?

YesNo
Details:
7. Were MRI's performed in the ER?

YesNo
Details:
8. What treatments/discharge instructions did you receive?

MedicationCaneTold to apply heatSurgeryCrutchesTold to apply iceCastTold to restBandagingCervical collarBack braceStitchesArm sling
OTHER TREATING DOCTORS AFTER THE ER
1. Doctor's Name/Speciality:
Diagnostic Testing:

MRICTX-raysOther
Treatments Received:

ChiropracticMassagePhysical TherapyUltrasoundElectrical StimMedicationsInjectionsTherapy
Benefit from treatment:

PartialCompleteNone
2. Doctor's Name/Speciality:
Diagnostic Testing:

MRICTX-raysOther
Treatments Received:

ChiropracticMassagePhysical TherapyUltrasoundElectrical StimMedicationsInjectionsTherapy
Benefit from treatment:

PartialCompleteNone
3. Doctor's Name/Speciality:
Diagnostic Testing:

MRICTX-raysOther
Treatments Received:

ChiropracticMassagePhysical TherapyUltrasoundElectrical StimMedicationsInjectionsTherapy
Benefit from treatment:

PartialCompleteNone
4. Doctor's Name/Speciality:
Diagnostic Testing:

MRICTX-raysOther
Treatments Received:

ChiropracticMassagePhysical TherapyUltrasoundElectrical StimMedicationsInjectionsTherapy
Benefit from treatment:

PartialCompleteNone
CURRENT STATUS OF SYMPTOMS
Since the accident symptoms are:

Completely RecoveredA Lot BetterWorseA Little BetterUnchanged
NERVOUSNESS
1. Are you nervous about driving?

YesNoConstantlyOccasionally
How often?
2. Do you have nightmares?

YesNoConstantlyOccasionally
How often?
3. Do you have flashbacks?

YesNoConstantlyOccasionally
How often?
4. Do you have intrusive thoughts?

YesNoConstantlyOccasionally
How often?
5. Do you have avoidance behavior?

YesNoConstantlyOccasionally
How often?
6. Are you easily startled?

YesNoConstantlyOccasionally
How often?
7. Do you have panic attacks?

YesNoConstantlyOccasionally
How often?
8. Do you have suicidal thoughts?

YesNoConstantlyOccasionally
How often?
HEADACHES
1. Have you experienced headaches since the accident?

YesNoConstantlyOccasionally
How often?
2. How severe are the headaches?

MildModerateSevereMild-ModerateModerate-SevereIncapacitating
3. How bad is the pain? (Level 10 being the highest)

1/102/103/104/105/106/107/108/109/1010/10
Range _____/10
4. Where is the pain located?

Front of headBehind EyesRight TempleHatband regionRight side of headLeft TempleAll overLeft side of headBoth Temples
5. Are the headaches preceded by vision loss, weakness or numbness?

YesNo
If yes, describe:
6. Describe headache quality

ThrobbingTensionShootingPressureSharp
7. Are Headaches accompanied by:
a) Sparkles in vision?

YesNoConstantlyOccasionally
b) Sensitivity to light?

YesNoConstantlyOccasionally
c) Sensitivity to sound?

YesNoConstantlyOccasionally
d) Nausea?

YesNoConstantlyOccasionally
e) Vomiting?

YesNoConstantlyOccasionally
f) Dizziness?

YesNoConstantlyOccasionally
g) Blurred vision?

YesNoConstantlyOccasionally
8. What relieves the headaches?

NothingMedicationIceRestDarkness
9. How long do the headaches last?
JAW PAIN
1. Have you experienced jaw pain since the accident?

YesNoConstantlyOccasionally
How often?
2. Have you experienced:

Pain when chewingPoppingClickingLocking
3. What relieves the pain?

NothingMedicationSoft dietSplint
JOINT PAIN
1. Have you experienced joint pain since the accident?

YesNoConstantlyOccasionally
How often?
2. How bad is the pain? (Level 10 being the highest)

1/102/103/104/105/106/107/108/109/1010/10
Range _____/10
3. Where is the pain located?

Right shoulderLeft shoulderRight elbowLeft elbowRight wristLeft wristRight handLeft handRight hipLeft hipRight kneeLeft kneeRight ankleLeft ankleRight footLeft foot
4. Is there limitation of motion?

YesNo
5. What makes it worse?

Range of motionWeight bearingStandingSittingBendingLying on sideActivities of daily living
6. What makes it better?

NothingRestMedicationInjectionsChiropractic therapyPhysical TherapyHeatIce
NECK PAIN
1. Have you experienced neck pain since the accident?

YesNoConstantlyOccasionally
How often?
2. How bad is the pain? (Level 10 being the highest)*

1/102/103/104/105/106/107/108/109/1010/10
Range _____/10
3. Where does the pain radiate?

Right shoulderLeft shoulderRight armLeft armRight handLeft hand
4. Where is the numbness/tingling located?

Right shoulderLeft shoulderRight armLeft armRight handLeft handIntermittentConstant
5. Where is the weakness located?

Right shoulderLeft shoulderRight armLeft armRight handLeft handIntermittentConstant
6. What makes it worse?

NothingRange of motionOverhead reachingWeight bearingStandingSittingBendingLying on sideActivities of daily living
7. What makes it better?

NothingRestMedicationInjectionsChiropractic therapyPhysical TherapyHeatIceStretchingTraction
MID BACK PAIN
1. Have you experienced mid-back pain since the accident?

YesNoConstantlyOccasionally
How often?
2. How bad is the pain? (Level 10 being the highest)

1/102/103/104/105/106/107/108/109/1010/10
Range (_____/10)
3. Where does the pain radiate?

NoAcross ribcageAcross shoulder bladesAround waist
4. Where is the numbness/tingling located?

NoRight ribcageLeft ribcageRight flankLeft flank
5. What makes it worse?

NothingRange of motionOverhead reachingWeight bearingStandingSittingBendingLying on sideActivities of daily living
6. What makes it better?

NothingRestMedicationInjectionsChiropractic therapyPhysical TherapyHeatIceStretchingTraction
LOW BACK PAIN
1. Have you experienced low back pain since the accident?

YesNoConstantlyOccasionally
How often?
2. How bad is the pain? (Level 10 being the highest)

1/102/103/104/105/106/107/108/109/1010/10
Range (_____/10)
3. Where does the pain radiate?

Right buttockLeft buttockRight legLeft legRight footLeft foot
4. Where is the numbness/tingling located?

Right buttockLeft buttockRight legLeft legRight footLeft footIntermittentConstant
5. Where is the weakness located?

Right buttockLeft buttockRight legLeft legRight footLeft footIntermittentConstant
6. What makes it worse?

NothingRange of motionOverhead reachingWeight bearingStandingSittingBendingLying on sideActivities of daily living
7. What makes it better?

NothingRestMedicationInjectionsChiropractic therapyPhysical TherapyHeatIceStretchingTraction
BOWEL BLADDER SYMPTOMS
Have you noticed loss of bowel or bladder control since the accident?

YesNoConstantlyOccasionally
How often?
Incomplete Voiding

Incomplete Voiding
Urgency

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

YesNoConstantlyOccasionally
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?

YesNoConstantlyOccasionally
How often?
2. Have you had lightheadedness since the accident?

YesNoConstantlyOccasionally
How often?
3. Have you felt the room spin?

YesNoConstantlyOccasionally
How often?
4. Have you felt off balance?

YesNoConstantlyOccasionally
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 symptomsExcessive sweatingAnxietyHeart palpitationsRinging of ears
8. What triggers the dizziness?

Quick movementsStanding suddenlyDrivingLoud noisesRolling overStress
SEIZURES
1. Have you had any seizures since the accident?

YesNo
If yes, how often?
2. How many seizures have you had?

12345+
3. Please describe the seizure:

Loss of consciousnessAutomatic repetitive movementsStaring spellsInvoluntary shaking/jerking
4. Any prior history of seizures?

YesNo
5. What did you feel before the seizure(s)?

NothingFeeling faintExcess sweatingAura perceptionNauseaChest pain
Aura Description:
6. What accompanied the seizure(s)?

Bowel incontinenceTongue bitingBladder incontinenceSelf injuryLoss of awarenessNo loss of awarenessNothing
7. Were the seizure(s) followed by a period of confusion?

YesNo
How long did the confusion last?
HEARING LOSS
1. Have you had hearing loss since the accident?

RightLeftConstantlyOccasionallyNo
How often?
2. Is your hearing muffled?

RightLeftConstantlyOccasionallyNo
How often?
3. Have you had ringing in the ears?

RightLeftConstantlyOccasionallyNo
How often?
4. Have you had ear pain?

RightLeftConstantlyOccasionallyNo
How often?
MEMORY LOSS
1. Have you had memory loss since the accident?

YesNoConstantlyOccasionally
How often?
Have you had any of the following (check all that apply)?

Short-term memory lossMisplaces objectsChanges in personalityForgetfulnessImpaired concentrationImpaired multitaskingGet lost in familiar placesHave to write things down to remember themMental instabilityImpulsivenessMood swings
MEDICAL HISTORY - Please list all current or past medical conditions - NOT RELATED TO THE INJURY
1. Check any current illnesses:

ADD/ADHDAlzheimer's disease/dementiaAnemiaAneurysmAnxietyArthritisAtrial fibrillationBipolar disorderBleeding disorderBrain tumorCancerCarpal tunnel syndromeChronic hepatitisCongestive heart failureCOPD/EmphysemaDeep vein thrombosisDepressionDiabetesDrug dependencyEpilepsyFibromyalgiaGastritisGERDFractureHeart attackHeart diseaseHemophiliaHigh cholesterolHIVHypertensionHyperthyroidismHypothyroidismInsomniaIrritable bowel syndromeJoint injuryKidney stoneKidney failureLiver failureMigraines/headachesMultiple sclerosisMuscular dystrophyNeuropathyParkinson's diseasePeptic ulcer diseasePrior back conditionPrior neck conditionPsoriasisScoliosisSleep apneaStrokeSurgical repair
2. Have you ever been injured in the past?

YesNoDon't Recall
If yes, please give details:
3. *FEMALES ONLY* Are you pregnant or planning pregnancy?

YesNo
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/ADHDDiabetes mellitusHigh cholesterolMuscular dystrophyAlzheimer'sEpilepsyHypertensionNeuropathyEye disease (Glaucoma/Cataracts)Inflammatory bowel diseaseParkinson's diseaseAnemiaPsychiatric illnessBrain aneurysmHearing lossKidney failureRheumatoid arthritisBrain tumorHeart attackLung diseaseScoliosisCancerLupusSkin diseaseCarpal tunnel syndromeHeart diseaseMigraines/HeadachesStrokeColon polypsThyroid diseaseOther:
SOCIAL HISTORY/PAST HISTORY
1. Do you smoke?

YesNo
Amount?
Number of years?
2. Do you drink alcohol?

YesNo
Amount?
3. Marital Status?

SingleMarriedDivorcedWidowed
4. Do you have children?

YesNo
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?

YesNo
If yes, which type of work?
7. Did you miss any days of work due to this accident/injury?

YesNo
If yes, how many days?
8. Are you currently employed?

YesNo
If yes, which type of work?
9. Check your highest level of education:

GEDHigh school graduateAA or AS degreeBA or BS degreeMaster'sDoctorateNo degree
Highest grade completed:
Years of college
REVIEW OF SYSTEMS
PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING SYMPTOMS:

Blurred VisionBlindnessDouble visionHearing lossRinging in the earsTemporomandibular Joint Dysfunction PainLoss of SmellLoss of TasteDifficulty ChewingDifficulty SwallowingDifficulty SpeakingDifficulty ReadingMemory LossHeadachesChange in Menstrual CycleMenopauseImpaired Sexual FunctionHigh CholesterolCoughShortness of BreathChest painPalpitationsHigh blood pressureDiabetesStrokeSeizuresLoss of consciousnessDizzinessLoss of BalanceTrouble WalkingDifficulty StandingTrouble Falling AsleepTrouble Staying AsleepPanic AttacksFeeling StressNervousnessLoss of Interest in ActivitiesDepressionWeight LossWeight GainWeaknessNumbness or TinglingJoint Pain or SwellingSwelling of the AnklesSkin Rash or LesionsStomach PainHeartburnChange in Bowel HabitsLoss of Bladder ControlLoss of Bowel ControlBlood in SputumBlood in StoolsFever or Chills
Should be Empty: