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#1 Problem
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Pain Rating (0-10, 10 is worst)
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#2 Problem
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Pain Rating (1-10, 10 is worst)
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3) Is the current problem from a work injury?
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If no, continue to Question 4.
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If yes, date of work injury *Then go to Part B*
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4) Is the current problem from an auto accident?
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If no, continue to Question 5.
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If yes, date of auto injury *Then go to Part C*
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5) Have you had a Work Injury in the last 10yrs?
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If yes, what year and what body part?
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6)Have you had an Auto Injury in the last 10yrs?
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If yes, what year and what body part?
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PART B - Workers Compensation
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Have you missed work due to this injury?
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Are you currently working?
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When was the last date you worked?
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PART C - Auto Accident
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Have you reported accident to your insurance?
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Your vehicle type
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If other, what type?
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What was your position in the vehicle?
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Collision Type
• • •
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Speed of your vehicle
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If moving, approximately how fast (MPH)?
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Other vehicle type
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If other, what type?
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Speed of other vehicle
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If moving, approximately how fast (MPH)?
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At the moment of impact, were you:
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At impact, were you using a seatbelt?
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At impact, what happened with the airbag?
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At impact, your head:
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If other, please explain.
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The position of your head was:
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The position of your body was:
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Damage to the vehicle you were in was
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Was a police report filed?
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Was a police citation given?
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Did you lose consciousness?
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How did you feel?
• • •
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Were you able to walk unaided?
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Where did you go after the accident?
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If other, please explain
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In what area(s) did you immediately feel pain?
• • •
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Did any new area(s) have pain following accident
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If yes, in what area(s) did you feel pain?
• • •
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How long after accident did symptoms appear?
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If other, please explain
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