|
Any additional notes
|
Any additional notes
|
|
Was the accident on-the-job?
|
Notes on accident on the job
|
|
You were?____
|
Other? (please specify)
|
|
Vehicle driven by?
|
Your vehicle (year, make, model)
|
|
moving status of your vehicle
|
Your estimated speed at moment of accident (MPH)
|
|
Other vehicle (year, make, model)
|
moving status of the other vehicle
|
|
The other vehicle's estimated speed (MPH)
|
Time segment of the day
|
|
Time
|
Road Conditions?
• • •
|
|
Other road conditions
|
Head restraint type
|
|
Head restraints
|
If adjustable, was the position altered by the accident?
|
|
Other Head restraint description
|
Lap Belt?
|
|
Shoulder Belt?
|
If does not remember shoulder belt
|
|
Was the seat broken?
|
Did airbag deploy?
|
|
If airbag deployed, were you struck?
|
if yes, body part struck by airbag (use preposition)
|
|
Body position?
|
Other body position? Please specify
|
|
Head position? Forward
|
|
|
Head Position: Left____º
|
Head Position: Right____º
|
|
Head Position: Up____º
|
Head Position: Down____º
|
|
other description of head position
|
Hand position - if applicable
|
|
Brakes applied?
|
Notes on brake / hand position
|
|
Accident description
|
|
|
Accident diagram
|
Aware of impending crash?
|
|
During the crash
|
|
|
Did you strike any parts of the vehicle?
|
If yes, describe_______
|
|
Did vehicle strike any objects after crash?
|
If yes, describe_______
|
|
If wearing hat/glasses/other?
|
Wore hat / glasses
• • •
|
|
hat / glasses on or off after crash
|
Hat / glasses notes
|
|
Did you lose consciousness?
|
If yes, for how long?_____
|
|
Car totaled
|
If not totaled - estimated damage to your vehicle (in $)
|
|
Estimated damage to other vehicle(s)
|
property damage to the other party
|
|
Were there police on the scene?
|
If yes, was a report made?
|
|
After the crash
|
Symptoms
• • •
|
|
Paresthesia?
|
If yes, where?___
|
|
Extremity pain?
|
If yes, where?___
|
|
ON is SX appeared immediately
|
Symptoms
• • •
|
|
paresthesia, extremity pain, etc. (add punctuation before & after)
|
|
|
Sx appeared later
|
_____hr afterwards
|
|
other notes on Sx appeared later, including when
|
other notes on Sx appeared later, including when
|
|
Where did you go after accident?
|
Mode of transportation____.
|
|
Notes on mode of transportation
|
Pvt. Doctor___
|
|
Emergency department
|
Radiographs
|
|
Body parts imaged?
|
Results remarkable?
|
|
Lab work?
|
Lab work notes (add punctuation)
|
|
Cervical collar
|
Ice
|
|
Notes on cervial collar / Ice (add punctuation)
|
Medications
|
|
Other notes
|
Follow-up instructions
|
|
Treatment history
|
|
|
Treatment history 1
|
Specialty:
|
|
Dr:
|
Referred by
|
|
Date first seen
|
TX frequency and duration
|
|
TX type
|
|
|
Currently treating?
|
If yes, describe____
|
|
Any disability?
|
Referred to
|
|
Special tests
|
Notes
|
|
Did TX help?
|
|
|
Treatment history 2
|
Specialty:
|
|
Dr:
|
Referred by
|
|
Date first seen
|
TX frequency & duration
|
|
TX type
|
|
|
Currently treating?
|
If yes, describe____
|
|
Any disability?
|
Referred to
|
|
Special tests
|
Notes
|
|
Did TX help?
|
|
|
Treatment history 3
|
Specialty:
|
|
Dr:
|
Referred by
|
|
Date first seen
|
TX frequency & duration
|
|
TX type
|
|
|
Currently treating?
|
If yes, describe____
|
|
Any disability?
|
Referred to
|
|
Special tests
|
Notes
|
|
Did TX help?
|
|
|
Treatment history 4
|
Specialty:
|
|
Dr:
|
Referred by
|
|
Date first seen
|
TX frequency & duration
|
|
TX type
|
|
|
Currently treating?
|
If yes, describe____
|
|
Any disability?
|
Referred to
|
|
Special tests
|
Notes
|
|
Did TX help?
|
|
|
Original chief complaints (if injury was not recent)
|
|
|
1. Body part/system
|
Body part/system_____
|
|
Onset
|
Provocative
|
|
Palliative
|
Quality
|
|
Radiation
|
additonal comments
|
|
Pt denies Radiation?
|
Severity
|
|
Temporal (with preposition)
|
1st Original Complaint Notes
|
|
2. Body part/system
|
Body part/system_____
|
|
Onset
|
Provocative
|
|
Palliative
|
Quality
|
|
Radiation
|
additonal comments
|
|
Pt denies Radiation?
|
Severity
|
|
Temporal (with preposition)
|
2nd Original Complaint Notes
|
|
3. Body part/system
|
Body part/system_____
|
|
Onset
|
Provocative
|
|
Palliative
|
Quality
|
|
Radiation
|
additonal comments
|
|
Pt denies Radiation?
|
Severity
|
|
Temporal (with preposition)
|
3rd Original Complaint Notes
|
|
4. Body part/system
|
Body part/system_____
|
|
Onset
|
Provocative
|
|
Palliative
|
Quality
|
|
Radiation
|
additonal comments
|
|
Pt denies Radiation?
|
Severity
|
|
Temporal (with preposition)
|
4th Original Complaint Notes
|
|
Current chief complaints
|
|
|
1. Body part/system (CCC)
|
Body part/system_____
|
|
Onset
|
Provocative
|
|
Palliative
|
Quality
|
|
Radiation
|
additonal comments
|
|
Pt denies Radiation?
|
Severity
|
|
Temporal (with preposition)
|
1st Chief Complaint Notes
|
|
2. Body part/system (CCC)
|
Body part/system_____
|
|
Onset
|
Provocative
|
|
Palliative
|
Quality
|
|
Radiation
|
additonal comments
|
|
Pt denies Radiation?
|
Severity
|
|
Temporal (with preposition)
|
2nd Chief Complaint Notes
|
|
3. Body part/system (CCC)
|
Body part/system_____
|
|
Onset
|
Provocative
|
|
Palliative
|
Quality
|
|
Radiation
|
additonal comments
|
|
Pt denies Radiation?
|
Severity
|
|
Temporal (with preposition)
|
3rd Chief Complaint Notes
|
|
4. Body part/system (CCC)
|
Body part/system_____
|
|
Onset
|
Provocative
|
|
Palliative
|
Quality
|
|
Radiation
|
additonal comments
|
|
Pt denies Radiation?
|
Severity
|
|
Temporal (with preposition)
|
4th Chief Complaint Notes
|
|
5. Body part/system (CCC)
|
Body part/system_____
|
|
Onset
|
Provocative
|
|
Palliative
|
Quality
|
|
Radiation
|
additonal comments
|
|
Pt denies Radiation?
|
Severity
|
|
Temporal
|
5th Chief Complaint Notes
|
|
Self assessment: % improved
|
notes on improvement
|
|
Request radiographs from_____
|
Request records from_____
|
|
Request copy of police report
|
|
|
Referral
|
To:_____
|
|
For:_____
|
|
|
Tests to order
|
|
|
Radiographs
|
|
|
Tomograms
|
Area(s)
|
|
CT
|
Area(s)
|
|
MRI
|
Area(s)
|
|
Scintigraphy/SPECT
|
Root level/nerve(s)
|
|
EMG/NCV
|
Root level/nerve(s)
|
|
SEP
|
|
|
Other electrodiagnostic test(s)
|
Area(s)
|
|
Ultrasound
|
|
|
Action taken on this visit
|
Place on disability
|
|
Exam/TX
|
Referral
|
|
Work restriction
|
Home traction device
|
|
Brace/collar
|
Supplements
|
|
NEXERCICER
|
Other
|
