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Patient Name
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Date of Injury
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Date of Service
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Attorney
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Insurance
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What type of incident were you in?
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When was the incident?
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Mechanism of Injury:
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Where in the vehicle where you positioned?
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Did you have on your seatbelt?
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Did the airbag deploy?
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Which direction were you looking?
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What body part/region made contact with the interior of the vehicle?
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What part of the interior of the vehcle did you make contact with?
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Did you injure your head in this incident?
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Did you lose consciousness at the time of the incident?
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Where was the vehicle struck?
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What was the patients movement?
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About how fast was your vehicle travelling?
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Estimated amount of damage done to the vehicle?
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Where was the OTHER vehicle struck?
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What was the OTHER VEHICLEs movement?
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About how fast was the OTHER vehicle travelling?
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Estimated amount of damage done to the OTHER vehicle?
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Was your vehicle towed from the scene?
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Did police arrive at the scene?
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Was a police report given after the incident?
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Did an ambulance or EMS arrive at the scene of the incident?
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What did you do after the incident?
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Where you treated since the incident?
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Symptoms felt after the incident.
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Area(s) of the body that experienced symptoms following the incident?
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Any addtional symptoms?
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Physical Examination
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Sex of the patient.
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Height
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Weight
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Pulse
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Blood Pressure
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Head Pain
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Aggravated by.
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Relieved by
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Neck Pain
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Aggravated by.
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Relieved by
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Shoulder Pain
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Aggravated by.
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Relieved by
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Upper Back
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Aggravated by.
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Relieved by
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Low Back Pain
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Aggravated by.
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Relieved by
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Pelvis/Glute/Buttocks Area Pain
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Aggravated by.
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Relieved by
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Thigh Area Pain
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Front or back
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Aggravated by.
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Relieved by
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Knee Pain
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Front or back
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Aggravated by.
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Relieved by
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Lower Leg
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Front or back
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Aggravated by.
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Relieved by
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Ankle/Foot/Toes
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Aggravated by.
• • •
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Relieved by
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Upper Arm Pain
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Aggravated by.
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Relieved by
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Elbow Pain
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Aggravated by.
• • •
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Relieved by
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Forearm Pain
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Aggravated by.
• • •
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Relieved by
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Wrist/hand/fingers
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Aggravated by.
• • •
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Relieved by
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Chest Pain
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Deep or closer to the surface?
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Aggravated by.
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Relieved by
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Abdominal Pain
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When did you feel the pain?
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Intensity of symptoms.
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Frequency of symptom.
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Symptoms associated with this body part/region.
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Left or Right side
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Aggravated by.
• • •
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Relieved by
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Deep or closer to the surface?
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Sleep Disturbance
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Sleep Disturbances?
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Past Medical History
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Prior incidents
• • •
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Approximately when was your prior incident?
• • •
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Past Surgical History
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Surgical History
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Details of the Surgical History
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Current Medication
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Currently taking medications
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List Current Medications
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Cranial Nerve Examination
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Normal Cranial Nerve Examination
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Abnormal Cranial Nerve
• • •
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Mental Status Examination
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Normal Mental Status Examination
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Abnormal Mental Status
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Musculoskeletal Examination
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Gait of the patient.
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Inspection/Percussion/Palpation
• • •
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Posture analysis
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Spinal Segmental Dysfunction
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Extraspinal Segmental Dysfunction
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Muscle Tone and Spasm
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Level of discomfort associated with spasm
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Cervical Spine Digital Palpation
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Where is the tenderness?
• • •
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Muscle with associated trigger points.
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Thoracic Spine Digital Palpation
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Where is the tenderness?
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Muscle with associated trigger points.
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Lumbar Spine Digital Palpation
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Where is the tenderness?
• • •
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Muscle with associated trigger points.
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Shoulder Digital Palpation
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Where is the tenderness?
• • •
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Muscle with associated trigger points.
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Upper arm Digital Palpation
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Where is the tenderness?
• • •
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Muscle with associated trigger points.
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Elbow Digital Palpation
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Where is the tenderness?
• • •
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Muscle with associated trigger points.
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Forearm Digital Palpation
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Where is the tenderness?
• • •
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Muscle with associated trigger points.
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Hip/pelvic girdle Digital Palpation
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Where is the tenderness?
• • •
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Muscle with associated trigger points.
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Knee Digital Palpation
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Where is the tenderness?
• • •
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Muscle with associated trigger points.
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Lower leg Digital Palpation
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Where is the tenderness?
• • •
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Muscle with associated trigger points.
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Range Of Motion
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New Short Text Field
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Cervical Spine:
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Cervical Spine
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Abnormal Ranges
• • •
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Thoracic Spine:
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Thoracic Spine
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Abnormal Ranges
• • •
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Lumbar Spine:
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Lumbar Spine
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Abnormal Ranges
• • •
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Shoulder:
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Shoulder
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Abnormal Ranges
• • •
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Elbow:
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Elbow
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Abnormal Ranges
• • •
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Wrist:
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Wrist
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Abnormal Ranges
• • •
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Hand/Digits:
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Hand/Digits
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Abnormal Ranges
• • •
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Hip/Pelvis:
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Hip/Pelvis
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Abnormal Ranges
• • •
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Knee:
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Knee
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Abnormal Ranges
• • •
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Ankle:
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Ankle
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Abnormal Ranges
• • •
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Foot/Digits:
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Foot/Digits
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Abnormal Ranges
• • •
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