|
|
|
|
Date of accident/injury
|
injury type
|
|
Injury unspecified
|
Desc. of Work injury
|
|
Position in vehicle
• • •
|
Impact location
• • •
|
|
Air bag
|
Seat Belt
|
|
initial symptoms
• • •
|
symptoms appeared
• • •
|
|
|
initial symptoms type in
|
|
hospital
• • •
|
ambulance
|
|
Hospital meds
• • •
|
Hospital-type in
|
|
Other Physicians/care
• • •
|
hospital procedures
• • •
|
|
Films or test for review
|
Prior treatment/recommendations
• • •
|
|
|
Notes
|
|
Symptoms
|
|
|
Symptom 1
|
quality
|
|
Constant/int
|
note
|
|
Symptom 2
|
quality
|
|
constant/int
|
Notes
|
|
symptom 3
|
quality
|
|
constant/int
|
note
|
|
Symptom 4
|
Quality
|
|
constant/int
|
note
|
|
Symptom 5
|
Quality
|
|
constant/int
|
note
|
|
Symptom 6
|
Quality
|
|
constant/int
|
note
|
|
Symptom unspecified
|
quality
|
|
constant/int
|
note
|
|
symptom unspecified
|
quality
|
|
constant/int
|
note
|
|
radiation
• • •
|
type
• • •
|
|
Radiation note
|
|
|
precipitating factors
• • •
|
Relief
• • •
|
|
prior history
• • •
|
prior pain level
• • •
|
|
New Field
|
|
