|
INITIAL VISIT TEMPLATE
|
|
|
Cause of Injuries
|
Date of Collision or Injury
|
|
Extra information
|
|
|
Headache
|
|
|
Side
|
Location
• • •
|
|
Radiating
|
Intensity
|
|
Timing
|
Quality
• • •
|
|
Aggravating factors
• • •
|
Alleviating factors
• • •
|
|
Free text
|
|
|
Chest
|
|
|
Side
|
Radiating
|
|
Intensity
|
Timing
|
|
Quality
• • •
|
Aggravating factors
• • •
|
|
Alleviating factors
• • •
|
Free text
|
|
Abdomen
|
|
|
Side
|
Location
|
|
Intensity
|
Timing
|
|
Quality
• • •
|
Aggravating factors
• • •
|
|
Alleviating factors
• • •
|
Free Text
|
|
Cervical
|
|
|
Side
|
Radiating
|
|
Intensity
|
Timing
|
|
Quality
• • •
|
Aggravating factors
• • •
|
|
Alleviating factors
• • •
|
Free text
|
|
Thoracic
|
|
|
Side
|
Radiating
|
|
Intensity
|
Timing
|
|
Quality
• • •
|
Aggravating factors
• • •
|
|
Alleviating factors
• • •
|
Free text
|
|
Lumbar
|
|
|
Side
|
Radiating
|
|
Intensity
|
Timing
|
|
Quality
• • •
|
Aggravating factors
• • •
|
|
Alleviating factors
• • •
|
Free text
|
|
Sacrum
|
|
|
Side
|
Radiating
|
|
Intensity
|
Timing
|
|
Quality
• • •
|
Aggravating factors
• • •
|
|
Alleviating factors
• • •
|
Free text
|
|
Hip
|
|
|
Side
|
Location
|
|
Radiating
|
Intensity
|
|
Timing
|
Quality
• • •
|
|
Aggravating factors
• • •
|
Alleviating factors
• • •
|
|
Free text
|
|
|
Upper Leg
|
|
|
Side
|
Location
|
|
Radiating
|
Intensity
|
|
Timing
|
Quality
• • •
|
|
Aggravating factors
• • •
|
Alleviating factors
• • •
|
|
Free Text
|
|
|
Knee
|
|
|
Side
|
Location
|
|
Radiating
|
Intensity
|
|
Timing
|
Quality
• • •
|
|
Aggravating factors
• • •
|
Alleviating factors
• • •
|
|
Free text
|
|
|
Lower Leg
|
|
|
Side
|
Location
|
|
Radiating
|
Intensity
|
|
Timing
|
Quality
• • •
|
|
Aggravating factors
• • •
|
Alleviating factors
• • •
|
|
Free Text
|
|
|
Foot and Ankle
|
|
|
Side
|
Location
• • •
|
|
Radiating
|
Intensity
|
|
Timing
|
Quality
• • •
|
|
Aggravating factors
• • •
|
Alleviating factors
• • •
|
|
Free text
|
|
|
Shoulder
|
|
|
Side
|
Radiating
|
|
Intensity
|
Timing
|
|
Quality
• • •
|
Aggravating factors
• • •
|
|
Alleviating factors
• • •
|
Free Text
|
|
Upper Arm
|
|
|
Side
|
Radiating
|
|
Intensity
|
Timing
|
|
Quality
• • •
|
Aggravating factors
• • •
|
|
Alleviating factors
• • •
|
Free Text
|
|
Elbow
|
|
|
Side
|
Location
|
|
Radiating
|
Intensity
|
|
Timing
|
Quality
• • •
|
|
Aggravating factors
• • •
|
Alleviating factors
• • •
|
|
Free text
|
|
|
Forearm
|
|
|
Side
|
Radiating
|
|
Intensity
|
Timing
|
|
Quality
• • •
|
Aggravating factors
• • •
|
|
Alleviating factors
• • •
|
Free text
|
|
Hand and Wrist
|
|
|
Side
|
Location
• • •
|
|
Radiating
|
Intensity
|
|
Timing
|
Quality
• • •
|
|
Aggravating factors
• • •
|
Alleviating factors
• • •
|
|
Free text
|
|
|
COLLISION DETAILS
|
|
|
Date and Time of Collision
|
Position in Car
|
|
Seat belt on?
|
Did Airbags Deploy?
|
|
Area of Impact
|
Patient Aware of Impending Crash?
|
|
Objects encountered from Impact
|
|
|
Additional collision details
|
|
|
Second impact
|
Location of second impact
|
|
Additional collision details
|
|
|
Head Rotation at Time of Impact?
|
Medical care after collision
|
|
Emergency Care received
• • •
|
|
|
CONCUSSION QUESTIONNAIRE
|
|
|
Loss of Consciousness?
|
Post-Traumatic Amnesia (Any period of disorientation to person, place, or time after accident)?
|
|
Post-Concussion Signs/Symptoms
• • •
|
|
|
Sleep disturbance
|
|
