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Turn this button ON if this visit is due to a current auto accident?
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Date of auto accident
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Time of auto accident
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In your own words, describe how the accident occurred
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What type of vehicle were you occupying?
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Were you the driver or passenger?
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Your vehicle's speed (approximate)
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Other vehicle's speed (approximate)
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Was this your car?
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If not, whom did the car belong to?
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What was your vehicle doing at the time of the accident?
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What was the visibility during the accident
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What were the road conditions?
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Where was your vehicle struck?
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Who hit who/what?
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Which direction were you looking?
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Did you strike anything in car?
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Did the airbags deploy?
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Seatbelts?
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Unconscious?
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Did the police show up at the scene?
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Where did you go after the accident?
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Did you have any Advanced Imaging or treatment?
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Dates the x-rays, MRI or CT were taken?
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What areas were taken?
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How are your symptoms today?
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Additional Treatment
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How often are your symptoms present?
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In the past week, how much has your pain interfered with your daily activities (work, social activities, household chores)?
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In general would you say your overall health right now is:
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Select the areas of pain you had after the accident?
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Rate your pain on a scale from 1-10
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Quality of pain
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Things that aggravate your condition
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Things that relieve your condition
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Treatment goals you'd like to see
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Other goals, describe?
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Turn this button ON if this visit is due to a work related accident?
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Date of the work accident
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Time of the work accident
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In your own words, describe the accident.
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Where did you go after the accident?
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Did you have any Advanced Imaging or treatment?
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Dates the x-rays, MRI or CT were taken?
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What areas were taken?
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How are your symptoms today?
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Rate your pain on a scale from 1-10
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Quality of pain
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How often are your symptoms present?
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In the past week, how much has your pain interfered with your daily activities (work, social activities, household chores)?
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In general would you say your overall health right now is:
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Things that aggravate your condition
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Things that relieve your condition
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Treatment goals you'd like to see
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Other goals, describe?
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Turn this button ON if today's visit is NOT related to an auto or work injury
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What brings you into the office today?
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What was the cause of injury
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When did your pain begin? (date)
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If "other," describe the incident
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Rate your pain on a scale from 1-10
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Quality of pain
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Did you have any Advanced Imaging or treatment?
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What areas were taken?
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Dates the x-rays, MRI or CT were taken?
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In general would you say your overall health right now is:
• • •
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In the past week, how much has your pain interfered with your daily activities (work, social activities, household chores)?
• • •
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How often are your symptoms present?
• • •
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Things that aggravate your condition
• • •
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Things that relieve your condition
• • •
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Treatment goals you'd like to see
• • •
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Other goals, describe?
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Select all the following symptoms that apply to your condition
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Select this button if you have neck symptoms and then choose below
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Neck Pain
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Headaches
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Sinusitis
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Migraines
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Numbness in right arm
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Tingling in right arm
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Numbness in left arm
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Tingling in left arm
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Pain in left arm
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Weakness in Grip
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Pain in right arm
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Coldness in Hands
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Tired and Heavy Shoulders
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TMJ / Jaw Pain / Clicking
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Thyroid Conditions
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Allergies / Hay Fever
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Select this button if you have upper/mid back symptoms and then choose below
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Upper-Back Pain
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Mid-Back Pain
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Pain on Deep Inhalation / Exhalation
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Pain on Cough / Sneeze
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Pain Into Ribs / Chest
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Heart Attacks / Angina
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Heart Palpitations / Murmurs
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Asthma / Wheezing
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Shortness of Breath
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Tachycardia
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Recurrent Lung Infections / Bronchitis
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High Blood Pressure
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Gallbladder Problems
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Low Blood Pressure
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Ulcers / Gastritis
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Reflux/Indigestion
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Diabetes
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Select this button if you have lower back symptoms and then choose below
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Low Back Pain
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Coldness in Legs / Feet
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Right Pelvis/SI joint Pain
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Left Pelvis/SI joint Pain
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Numbness in right leg
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Tingling in right leg
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Numbness in left leg
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Tingling in left leg
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Pain in right leg or foot
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Weakness in left leg or foot
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Pain in left leg or foot
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Weakness in right leg or foot
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Frequent / Difficulty Urinating
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Kidney / Liver Trouble
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Diarrhea / Constipation
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Menopausal Trouble
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Recurrent Bladder Infections
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Bed-wetting
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Menstrual Irregularities
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Sexual Dysfunction
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Select this button if you have extremity symptoms and choose below
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Hip
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Right Hip
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Select this button if you have additional conditions and choose below
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Alcohol/Drug dependance
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Recent fever
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Ear Infections
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Colic/Gassiness
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Reflux
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High Blood Pressure
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Diabetes
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Corticosteroid Use (Cortisone, Prednisone, etc)
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Stroke
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Dizziness/Fainting
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Taking Birth Control Pills
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Osteporosis
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Numbness in Groin/Buttocks
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Trouble Sleeping
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Cancer/Tumor
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Explain your Cancer or Tumor
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Epilepsy/Seizures
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Prostate Problems
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Menstrual Problems
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Urinary Problems
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Abnormal Weight Gain
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Abnormal Weight Loss
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Marked Morning Pain/Stiffness
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Pain Unrelieved by Position or Rest
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Pain at Night
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Visual Distrubances
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Anxiety
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Depression
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Doctor's Comments
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