IME QUESTIONNAIRE

IME QUESTIONNAIRE
Name
Sex

MaleFemale
Date of Birth

MonthDayYear
Date
Age
Height:
Weight (lbs.):
Are you right handed or left handed?

Right HandedLeft Handed
Hair Color

BlackBrownBlondeGrayWhiteBaldRedOther
Eye Color

BlackBrownBlueGreenHazelOther
Did you bring photo ID?

YesNo
Accompanied in exam room by:

ParentSpouseTranslatorAttorneyFriend
Name of person accompanying you:
EMPLOYMENT:
Were you employed at the time of accident?

YesNo
Occupation
Full Time or Part Time?

Full TimePart Time
Did you lose time from work due to the accident?

YesNo
If yes, how long?

daysweeksmonthsyearshave not returned to work since the accident
Are you working now?

NoYes
If yes,

Full TimeSame JobPart TimeLight Duty
New Job
Date began

MonthDayYear
Date
PAST MEDICAL HISTORY:
Have you been involved in a prior car or work related accident or had any other injuries?

NoYesMultiple prior accidents
Date

MonthDayYear
Date
Type of Accident
Areas Injured
(If multiple accidents use other side of page) Did you use the other side of page?

NoYes
Have you ever had neck or back complaints prior to this accident?

NoYes
If yes, explain
Have you ever had any surgery NOT related to this accident?

NoYes
If yes, explain
Do you have any illness of health conditions?

NoYes
If Yes,

DiabetesArthritisHigh Blood PressureCancerUlcersAsthmaOther
Other
FOR MOTOR VEHICLE ACCIDENTS:
Date of Accident

MonthDayYear
Date
Were you:

DriverPassenger in FrontPassenger in BackPedestrianBicyclist
Were you wearing a seatbelt?

NoYes
Was your car hit in the (check all that apply)

FrontRearRight SideLeft SideHead OnAir Bag Deployed
OTHER ACCIDENT DETAILS
HOSPITAL TREATMENT:
Did you go to a hospital or ER?

NoYes
if yes, date

MonthDayYear
Date
Hospital Name
Did you go by ambulance?

NoYes
Were x rays taken in the hosptial?

NoYes
If yes, what body parts?
Did you have a CAT scan?

NoYes
If yes, what body parts?
Did you lose consciousness?

NoYes
Were you bleeding?

NoYes
If yes, where?
Were you bruised?

NoYes
If yes, where?
Did you have any fractures?

NoYes
If yes, where?
What type of treatment did you receive in the hospital/ER?

MedicationInjectionCaneCrutchesArm SlingNeck CollarMRIAce BandageAdvised to restStitches
If you had stitches, how many?
Where?
If you had surgery, where was it?
Were you admitted to the hospital?

NoYes
If yes, date discharged

MonthDayYear
Date
Physical Complaints:
At the time of the accident, what areas of your body were injured?
Due to the accident, in what parts of your body are you CURRENTLY experiencing pain?
Do you have tingling/numbness in the (Circle all that apply):

Right Arm/HandLeft Arm/HandRight Leg/FootLeft Leg/FootNo tingling/numbness
Does pain shoot from the neck into the

Right Arm/HandLeft Arm/HandNeither
Does pain shoot from the lower back into the

Right Leg/FootLeft Leg/FootNeither
What types of treatment have you received?

Physical TherapyChiropractic TherapyAcupuntureMassage TherapyAqua Massage
What was the first date of treatment?
How often was treatment? (times a week/month)
What types of treatment do you receive presently?

Physical TherapyChiropractic TherapyAcupunctureMassage TherapyAqua Massage
How often presently?
Discontinued (When?)
Check the other types of treatment/services you have received

Manipulation under AnesthesiaSpinal DecompressionTrigger Point InjectionsDentistEpidural InjectionsOrthopedistNeurologistPsychologistPain Management Dr
List the Doctors you've seen, starting with Clinic Name:
Doctors Name
Specialty
Doctor Name
Specialty
Doctor Name
Specialty
Doctors Name
Specialty
Do you take medication? If yes, names
Did you take PAIN medication today? If yes, what medication?
How long ago (hrs)
Are you..

ImprovingWorseningNot ImprovingTreatment provides only temporary benefit
Have you been issued any medical supplies (suministros medicos) for use at home?

YesNo
List supplies issued if any
Were you instructed on how to use the supplies?
Were you measured for fitting?
Are you using any assistive devices?

CaneCrutchesWalkerWheel ChairOther
Are you wearing supports or braces today? If yes, where?
Did you have surgery after the accident?

YesNo
If yes, when?
On what body part?
Name of surgeon
DIAGNOSTIC TESTING: (PLEASE LIST AREAS TESTED)
MRI
CAT SCAN
X RAYS
Check any that were performed

EMG/Nerve TestingDiagnostic UltrasoundOther Test
Do you smoke? If so how many packs daily?
How long have you smoked?
Do you drink? (How much & how often)
Do you volunteer anywhere? (what & how long ago)
How do you spend your time during the day? (household chores, responsibilities, shopping, cleaning, etc)
Are you able to drive a car? If so, any restrictions?
What are your physical limitations? What are you physically unable to do, or can you no longer do since the accident?
Do you have any sitting, lifting, bending and/or standing restrictions? If so, what Doctor placed these restrictions?
Do you have any Hobbies?
Are you able to perform the following daily living activities? If no, why not?
Dressing
Driving
Sitting
Standing
Walking
House Chores
Meal Preparation
Bathing
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

IME QUESTIONNAIRE

EMPLOYMENT:

PAST MEDICAL HISTORY:

FOR MOTOR VEHICLE ACCIDENTS:

HOSPITAL TREATMENT:

Physical Complaints: