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Is this related to an automobile accident?
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AUTOMOBILE ACCIDENT HISTORY
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Date of Injury
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Where were you seated in the vehicle?
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Name of person driving the vehicle
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Your Vehicle (year, make, model)
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Your estimated speed at the moment of accident
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Please select
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If stopped, was your foot on the brake
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Other Vehicle (year, make, model)
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Estimated speed of the other vehicle
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Please select
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Road condition at the time of the accident
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Time of day:
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Head restraints, Seat backs:
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Distance of headrest/seatback from back of head
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Position of the headrest altered by the accident
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Seat back adjustment altered by the accident?
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Speed of the other vehicle at moment of impact
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Was the seat broken?
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Seat belts and Air bags:
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Were you wearing a seatbelt?
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What Type
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Did your air bag deploy?
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If yes, were you struck?
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Where?
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Head and Body position:
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Which way body pointed at point of impact
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Which way head pointed at point of impact
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DURING THE CRASH:
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Position of hands:
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Did you strike any parts of the vehicle?
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If yes, please describe
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Did vehicle strike any objects after the crash?
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If yes, please describe
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You aware/surprised of approaching collision?
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If yes, were they still on after the crash
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Were you wearing a hat or glasses?
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Did you lose consciousness upon impact?
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If yes, how long?
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Experience a flash of light/explosion in head?
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AFTER THE CRASH
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Did you become
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Still have any of those symptoms, which one
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Are you currently suffering from
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Did the police come to the accident scene
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Is there a report?
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DISABILITY
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Do you have a permanent disability rating?
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Location
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Date received
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Rating Percentage
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HOSPITAL
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Did you go to the hospital?
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How did you get to the hospital?
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Name and city of hospital
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Name of emergency room doctor
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What parts of body were x-rayed at the hospital
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How long did you stay in the hospital?
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What did the hospital do for your injuries?
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Medications
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Follow up instructions
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Treatment related to this accident
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1. Name
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Address
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Phone #
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Specialty
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Dates of care
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Tests/Treatments
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Results
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2. Name
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Address
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Phone #
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Specialty
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Dates of care
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Tests/Treatments
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Results
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HEALTH HABITS
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Do you consume tea, coffee?
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If yes, how much per day or week?
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Do you consume liquor?
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If yes, how much per day or week?
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Do you consume tobacco?
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If yes, how much per day or week?
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Do you consume sugar, candy, ice cream?
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If yes, how much per day or week?
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Exercise: Type
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Frequency
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Exercise: Type
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Frequency
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Exercise: Type
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Frequency
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Hours of sleep per night
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Type of mattress
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Naps
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Do you sleep on your
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Please describe your sleep
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Special diets
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Select the following you have or had
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Other
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CURRENT COMPLAINTS -
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1) Current symptoms /complaints
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Date when symptom first appeared
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How often do you experience the symptoms?
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Describe any recently related accident or fall
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What makes symptom increase?
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Type of pain:
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What gives relief of symptom?
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How bad is your pain?
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Where does the pain radiate to?
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Body Diagram
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2) Current symptoms /complaints
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Date when symptom first appeared
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How often do you experience the symptoms?
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Describe any recently related accident or fall
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What makes symptom increase?
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What gives relief of symptom?
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Type of pain:
• • •
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Where does the pain radiate to?
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How bad is your pain?
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Body Diagram
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3) Current symptoms /complaints
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Date when symptom first appeared
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How often do you experience the symptoms?
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Describe any recently related accident or fall
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What makes symptom increase?
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What gives relief of symptom?
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Type of pain:
• • •
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Where does the pain radiate to?
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How bad is your pain?
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Body Diagram
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4) Current symptoms /complaints
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Date when symptom first appeared
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How often do you experience the symptoms?
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Describe any recently related accident or fall
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What makes symptom increase?
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What gives relief of symptom?
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Type of pain:
• • •
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Where does the pain radiate to?
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How bad is your pain?
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Body Diagram
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5) Current symptoms /complaints
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Date when symptom first appeared
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How often do you experience the symptoms?
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Describe any recently related accident or fall
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What makes symptom increase?
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What gives relief of symptom?
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Type of pain:
• • •
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Where does the pain radiate to?
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How bad is your pain?
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Body Diagram
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PAST HEALTH HISTORY
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Type of surgeries you had and date?
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Doctor
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List previous fractures/dislocations
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Date
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List prior history of current complaints:
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Date
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Treatment
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Result
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Prior accidents, associated complaint
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Date
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Treatment
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Result
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What vitamins do you currently take?
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Frequency
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Doctor
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OCCUPATIONAL INFORMATION
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Job Involves:
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How long?
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Please select
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Other
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Job involves lifting
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How much weight
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Please select
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Type of shoes
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Other
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How long do you speak on the telephone each day
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Please select
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Physical activity at work
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work activities aggravate your present complaint
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If yes, please describe
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X-RAY CONFIRMATION- FEMALES
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Signature
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