Accident History Questionnaire

Accident History Questionnaire

PERSONAL INJURY PATIENT HISTORY
Patient Name*

First NameLast Name
Today's Date*

MonthDayYear
Today's Date
1. Date of Accident*

MonthDayYear
Date of Accident
2. Time of accident*
3. Driver of Car:*
4. Where were you seated?*
5. Who owns the car?*
6. Year & Model of your car
Year and Model of other car
7. What was the approximate damage done to your car: $*
8. Visibility at time of accident:*

poorfairgoodOther
9. Road conditions at time of accident:*

icyrainywetcleardarkOther. Describe:
10. Where did the accident impact your car*

FrontRearFront passenger side quarter panelRear passenger side quarter panelFront driver side quarter panelRear driver side quarter panelBroad side, passenger sideBroad side, driver side
In your own words, please describe accident*
11. Type of Collision:*

Head-onBroad-sideFront ImpactRear-end car in frontRear impactNon-collision
12. At the time of the accident, recall what parts of your head or body hit what parts on the inside of your car:*
13. Did you see the accident coming?*

yesno
14. Did you brace for impact?*

yesno
15. Were seatbelts worn?*

yesno
16. Were shoulder harnesses worn?*

yesno
17. Does your car have headrests?*

yesno
18. If yes, what was the position of those headrests compared to your head before the accident?*

Top of headrest even with BOTTOM of HEADTop of headrest even with TOP of HEADTop of headrest even with MIDDLE of NECKOther
19. Was your car breaking?*

yesno
20. Was your car moving at he time of the accident?*

yesno
21. If yes, how fast would you estimate you were going, mph?*
22. How fast would you estimate the other car was going, mph?*
23. Head/Body position at the time of impact:*

Head turned left/rightHead looking backHead straight forwardBody straight in sitting positionBody rotated right/leftOther
24. As a result of the accident you were:*

Rendered unconsciousIn shockDazed, circumstances vagueOther
25. How was your shoulder harness adjusted:*

LooseSnug
26. Were you wearing glasses?*

YesNo
27. Could you move all parts of your body?*

YesNo
28. If no, what parts couldn't you move and why?*
29. Were you able to get out of the car and walk unaided?*

YesNo
30. If no, why not?*
31. Did you get any bleeding cuts?*

YesNo
If yes, where?
32. Did you get any bruises?*

YesNo
If yes, where?
33. Describe how you felt immediately after the accident.*
Later that day*
The next day*
34. Check symptoms apparent since the accident:*

HeadacheAnxious/NervousnessNumbness in fingersFacial painIrritabilityTensionDiarrheaChest painPain behind eyesLoss of smellLoss of memoryDepressionConstipationNeck pain/StiffnessDizzinessNumbness in toesFatigueRinging/BuzzingCold handsMid back painLow back PainFaintingBreath shortnessCold SweatsClicking/Popping jawLight sensitivitySleeping problemsCold FeetLoss of tasteLoss of balanceOther
35. Occupation*
36. Employer*
37. Have you missed time from work?*

YesNo
38. If yes, Period of FULL time work missed: From: Date To: Date
39. If yes, Period of PART time work missed: From: Date To: Date
40. Did you seek medical help immediately after the accident?*

YesNo
41. If yes, how did you get there?

AmbulancePoliceSomeone drove meDrove myselfOther
42. Name of 1st Doctor or Facility consulted:
43. First Visit Date

MonthDayYear
Date
44. Were you examined?

YesNo
45. Were x-rays taken?

YesNo
46. Did you receive treatment? Yes No
Check if received: Medications Braces Collars Received Nothing
47. If yes, what kind of treatment did you receive?
48. What benefits did you receive from the treatment?
49. Date of last treatment

MonthDayYear
Date
50. Name of 2nd Doctor or Facility consulted:
51. First Visit Date

MonthDayYear
Date
52. Were you examined?

YesNo
53. Were x-rays taken?

YesNo
54. Did you receive treatment? Yes No
Check if received: Medications Braces Collars Received nothing
55. If yes, what kind of treatment did you receive?
56. What benefits did you receive from the treatment?
57. Date of last treatment

MonthDayYear
Date
58. Do you have an attorney on this claim?*

YesNo
59. If yes, who?
Attorney Name:   Attorney Full Name
Law Firm: Law Firm
Street Address:    Street Address  Suite/Apt/ P.O. Box: Address Line 2
City, State, Zip: City   State   Zip
Phone Number:Area Code   Phone Number
Illustrate how the accident happened. (This can be done in our office)
PAST MEDICAL HISTORY:
Concerning your past medical history, check if any relate to current complaint(s):    None realted to current complaints   Hospital or operation   Auto Accident   Work Accident   Illness   other
Describe "other" situation related to current complaint(s) or leave blank if "other" was not selected:   describe other
Describe past medical history related to current complaint(s) or leave blank if you selected "none":   past medical history
FAMILY HISTORY: Check if any family member has suffered from:*

TuberculosisDiabetesCancerKidney DiseaseGoutMigrainesSpinal DisorderAllergyHeart AttackMental IllnessArthritisEpilepsyHypertensionNoneOther
PERSONAL HISTORY: Check if it applies*

SingleMarriedDivorcedSeparatedWidow/Widower
If married, is spouse employed?*

YesNo
Number of Children*
Number of Children at home*
Female only: Are you pregnant?

YesNoNot sure
Medications, describe:
Disease, describe:
Other, describe
SYSTEM REVIEW

For each of the systems, check the symptoms you know you have
GENITO-URINARY SYSTEM:*

Bladder troubleExcessive urinationScanty urinationPainful urinationDiscolored urineNone of the above
GASTRO-INTESTINAL SYSTEM:*

Poor appetiteExcessive hungerDifficult chewingDifficult swallowingExcessive thirstNauseaVomiting foodAbdominal painDiarrheaConstipationBlack stoolBloody stoolHemerrhoidsLiver troubleWeight troubleGall bladder troubleNone of the above
NERVOUS SYSTEM:*

NumbnessLoss of feelingParalysisDizzinessFaintingHeadachesMuscle jerkingConvulsionsForgetfulnessConfusionDepressionNone of the above
CARDIO-VASCULAR SYSTEM:*

Chest painPain over heartDifficult breathingPersistent coughCoughing bloodCoughing phlegmRapid heartbeatHigh blood pressureHeart problemsLung problemsVaricose veinsNone of the aboveOther
EYES, EARS, NOSE and THROAT SYSTEM:*

Eye strainEye inflammationVision problemsEar painEar noisesEar dischargeHearing lossBreathing difficultyNose bleedingNose DischargeSore gumsNose painSore mouthSore throatHoarsenessSpeech difficultyDental problemsNone of the above
ACTIVITIES OF DAILY LIVING ASSESSMENT

Directions: This questionnaire has been designed to give the doctor information as to how your pain has affected your ability to manage in everyday life. Please check one item in each section which most closely applies to you.
SECTION 1: PAIN INTENSITY*

I can tolerate the pain I have without using pain killersThe pain is bad but I manage without taking pain killersPain killers give complete relief from painPain killers give moderate relief from painPain killers give very little relief from painPain killers give no relief from pain. I do not use them.
SECTION 2: PERSONAL CARE*

I can look after myself normally without causing extra painI can look after myself normally but it causes me extra painIt is painful to look after myself and I am slow and carefulI need some help but manager most of my personal careI need help every day in most aspects of self careI do not get dressed, wash with difficulty and stay in bed
SECTION 3: LIFTING*

I can lift heavy weights without causing extra painI can lift heavy weights but it causes me extra painPain prevents me from lifting heaby weights off the floor but I can manage if they are conveniently positioned (on a table)Pain prevents me from lifting heavy weights. I can manage light to medium weights if they are conveniently positioned.I can lift only very light weightsI cannot lift of carry anything at all
SECTION 4: WALKING*

Pain does not prevent me from walking any distancePain prevents me from walking more than one milePain prevents me from walking more than 1/2 milePain prevents me from walking more than 1/4 mileI can only walk using a cane or crutchesI am in bed most of the time and have to crawl to the toilet
SECTION 5: SITTING*

I can sit in any chair as long as I likeI can only sit in my favorite chair as long as I likePain prevents me from sitting for more than one hourPain prevents me from sitting for more than 30 minutesPain prevents me from sitting for more than 10 minutesPain prevents me from sitting at all
SECTION 6: STANDING*

I can stand as long as I want without extra painI can stand as long as I want but it causes extra painPain prevents me from standing for more than one hourPain prevents me from standing for more than 30 minutesPain prevents me from standing for more than 10 minutesPain prevents me from standing at all
SECTION 7: SLEEPING*

Pain does not prevent me from sleeping wellI can sleep well only by using a sleep aidEven when I take a sleep aid I have less than 6 hours sleepEven when I take a sleep aid I have less than 4 hours sleepEven when I take a sleep aid I have less than 2 hours sleepPain prevents me from sleeping at all
SECTION 8: SEX LIFE*

My sex life is normal and causes no extra painMy sex life is normal but causes some extra painMy sex life is nearly normal but is very painfulMy sex life is severely restricted by painMy sex life is nearly absent because of painPain prevents me from any sex life at all
SECTION 9: SOCIAL LIFE*

My social life is normal and causes no extra painMy social life is normal but increases the degree of painPain has no significant effect on my social life apart from limiting my more energetic interest (dancing, etc)Pain has restriced my social life and I do not go out as oftenPain has restricted my social life to my homeI have no social life because of pain
SECTION 10: Traveling*

I can travel anywhere with no extra painI can travel anywhere but it gives me extra painPain is bad but I manage journeys over 2 hoursPain restricts me to the journeys of less than one hourPain restricts me to short necessary trips under 1/2 hourPain restricts me from traveling except to the doctor or hospital
CURRENT CHIEF COMPLAINTS:

Check areas where you have a complaint:
SPINE

Low backMid backNeckPelvis
UPPER EXTREMITY

Shoulder R/LArm R/LElbow R/LWrist R/LForarm R/LHand R/L
LOWER EXTREMITY

Hip R/LThigh R/LKnee R/LLeg R/LAnkle R/LFoot R/L
Other Complaints (describe):
SUBJECTIVE PAIN LEVEL: (On a scale of 1 -10, with 1 = NORMAL and 10 = EMERGENCY, rate your current pain level*

12345678910
Mark the areas of your body where you feel numbness or burning or pins and needles or pain. Include all affected areas. (Different size DOTs can be placed on these areas)
Patient's Signature

Clear
Email address for confirmation email:*
example@example.com
Should be Empty:

Accident History Questionnaire

PAST MEDICAL HISTORY:

SYSTEM REVIEW

ACTIVITIES OF DAILY LIVING ASSESSMENT

CURRENT CHIEF COMPLAINTS: