Auto Accident Questionnaire

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1 Auto Accident Questionnaire Patient s Name: Date Of Accident: Date: Social History: (please complete the following, check all boxes that apply) Are you: Married Single Divorced Widowed # of Children: # of Children Living with you: Caffeine: (#of drinks per day) Drinking Alcohol: Never Often Occasional Social Smoking : (packs per day) Do you exercise? Yes No If yes, How often (# of times per week) Exercising since accident: Yes No What type of exercise? Employed: Yes No If employed, Full Time Part Time Occupation: Has accident affected work duties: Yes No If yes, What is affected: Do you feel your weight has affected your symptoms: Yes No If yes, how: Stress Level: Scale 1 to 10 (10 being the worst) Stress Due to: Additional Comments: Past Medical History: (Please check yes or no, If yes, describe incident in the space provided) Broken Bones: Yes No If yes, please describe: Fractures: Yes No If yes, please describe: Knocked Unconscious: Yes No If yes, please describe: Previous Falls: Yes No If yes, please explain Previous Auto or Work Injuries: Yes No If yes, please explain: Hospitalization: Yes No If yes, please explain: Surgeries: Yes No If yes, please explain: Serious Disease: Yes No If yes, please explain: Additional Comments: History of Injury: Were you the: Driver Front Seat Passenger Back Seat Passenger On the job at the time of accident Description of vehicle you were in: Make Model Year Transmission type: Standard (Stick) Automatic Portion of the vehicle hit: Right Front Left Front Right Rear Left Rear Right Side Left Side Other: Description of other vehicle: Make Model Year Was the car stopped at the time of the accident? Yes No If you were the driver, was your foot on the brake? Y/N Was vehicle moving at the time of impact: Yes No If yes, was car Slowing down Gaining speed Steady rate of speed Estimated rate of speed? (M.P.H.) Time of day: Daylight Dawn Dusk Dark Unknown

2 Road conditions: Dry Damp Wet Snow Ice Other Head Restraints: Up Down Don t know Seat Position after accident: Was altered Was not altered Don t know Seat after accident: Broken Not broken Lap Seatbelt: Worn Not Worn Don t Know Shoulder Seatbelt: Worn Not Worn Don t Know Air Bag Deployed: Yes No If Yes, were you Struck Not Struck Body position at time of accident: Good Forward Leaning Other Don t know Head Position: Forward Left Right Up Down Don t Know Other Hand s on Wheel? Yes No Aware of Crash: Aware Surprised Did you brace yourself? Yes No If yes, Braced with Arms Braced with Legs Did this cause further injury: Yes No If yes, please explain During/After Crash: Patient s body: Jolted Thrown about Stunned Dazed Whipped Slammed Other Did Patient s body strike interior of car: Yes No If yes, please complete all that apply: My Head hit My Right Left Shoulder hit My Right Left Hip hit My Right Left knee hit My Chest hit My Right Left arm hit My Right Left leg hit My Other body part hit Were you wearing glasses at the time of the accident? Yes No If yes, were the glasses still in place after impact? Yes No Unconscious? Yes No If yes, unconscious for (# of minutes) Estimated amount of Property Damage $ Damage to the other car: minimal moderate major totaled Was anyone cited: Yes No After accident, I had the following: headache dizziness nausea confusion disorientation neck pain Other Symptoms first appeared: Immediately hours after the accident the next day days after accident # I went: home work hospital family physician other

3 If you went to the hospital after the accident please complete the following: Name of hospital: How did you get to hospital? Ambulance What body parts were x-rayed, what treatment was given? What did they tell you was wrong? How long did you stay at hospital? Did you sustain bleeding cuts during the accident? Yes No If yes, describe: Did you sustain bruises during the accident? Yes No If yes, describe: Prescribed: Pain Pills Muscle relaxers Anti-Inflammatory Over the counter medications taken: Chief Complaints: BACK PAIN (If checked, please complete the following) I have pain in my: Lower back Mid back Upper back Pain Between Shoulder Blades My pain began: Gradually Suddenly I have pain Sometimes Constant Off and On Other How long does the pain usually last: hours days All the time My pain goes into: Right leg Left leg Both legs I have tingling numbness: Right leg Left leg Both My pain is worse when I: Cough Sneeze Sit Bend Walk Lift Push Pull Stand for long periods Lie Down My back is worse with sexual activity: Yes No Can you describe the sensation: Dull Sharp Throbbing Burning Aching Shooting Constricting Stiff My pain wakes me up during the night? Yes No Changes in the weather affect my pain? Yes No How would you describe the intensity? Mild Moderate Severe Comes and goes Has your condition been: Constant Intermittent Has your condition been: Better Worse About the same What makes the pain worse: Positions Activities Morning Evening Coughing Sneezing Has your condition affected your daily activities in any way? Work Sleep Daily Routine Housework Recreation If yes to the above, explain: Have you tried store bought or home remedies: Yes No Explain

4 NECK PAIN: (If check, please complete the following) I have neck pain: Yes No My pain began: Gradually Suddenly I have pain Sometimes Constant Off and on Other How long does the pain usually last: hours days All the time My pain goes into my: Right arm Left arm Both arms I have tingling and or numbness in my: Right arm Left arm Both arms Right hand Left hand My pain is worse when I: Sneeze Sit Bend Forward Walk Lift Push Pull Turn Head Other: Can you describe the sensation: Dull Sharp Throbbing Burning Aching Shooting Constricting Stiff My pain wakes me up during the night: Yes No Changes in the weather affect my pain: Yes No I have neck stiffness: Yes No I have dizziness: None Sometimes I have headaches: None Sometimes All the time If, yes where are the headaches located: How would you describe the intensity of your pain? Mild Moderate Severe Comes and goes Has your condition been: Constant Intermittent If yes, explain: Has your condition been: Better Worse About the same What makes the pain worse: Positions Activities Morning Evening Coughing Sneezing Has your condition affected your daily activities in any way? Yes No If yes, explain: Have you tried store bought or home remedies: Yes No Explain

5 Other Pain: (If check, please complete the following) I have pain in my: Right Shoulder Left Shoulder Right Arm Left Arm Right Elbow Left Elbow Right Wrist Left Wrist Right Hip Left Hip Right Knee Left Knee Right Ankle Left Ankle My pain began: Gradually Suddenly I have pain: Sometimes Constant Off and on Other The pain usually last: hours days All the time My pain is worse when I: Can you describe the sensation: Dull Sharp Throbbing Burning Aching Shooting Constricting Stiff My pain wakes me up during the night: Yes No Changes in the weather affect my pain: Yes No How would you describe the intensity of your pain? Mild Moderate Severe Comes and goes Has your condition been: Constant Intermittent If yes, explain What makes the pain worse: Positions Activities Morning Evening Coughing Sneezing Has your condition affected your daily activities in any way? Yes No If yes, explain: Have you tried store bought or home remedies: Yes No Explain:

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