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1 Name, Today's Date Accident Date Please answer the following questions as accurately and honestly as possible. This fonn is very important and will aid your doctor in providing you the best ~ as well as provi~ your attorney. with a complete and accurate medico-legal narrative report if one is needed. If unable to answer a question, please circle the number of the question in the left hand margin. YOU MUST MARX EVERY QUFSI'ION. 1. Describe how the accident bappened, road ronditions, time of day, daylight or dark andthe directions the vehicles '1 were traveling with the names of the streets. BE SPECIFIC. 2. Please draw a diagram of the amount of damage to your vehicle Example:.~. co Co 3. Please attempt to reconstruct the accident as best as you can. The vehicle you were in (or motorcycle or bicycle you were on) is vehicle #1 (VI). Use V2, V3, etc. for the other vehicles involved. Use arrows to indicate the path of vehicles. The UNSHADED CARS indicate the position of the vehicles AT THE TIME OF IMPACT. The SHADED CARS indicate the position oc the vehicles after the accident. Please label all streets if known. Example: 1

2 ACCIDENT msroar 1. Please describe your vehicle: Year...;., Make Modcl ~,~ 2. Please describe nther vehicle(s): VeHicle#2: Year Make Model Vehicle #3: Year Make Model...,... Vehicle #4: year Make Model 3. Is your care quipped with head rests? o No 0 Yes 4. They are: 0 part of the seat back 0 adjustable - In what position were they? 0 Up 0 Down 5. Were you wearing a seat bclt? D No Dyes 6. Were you wearing a shoulder harness? 0 No 0 Yes - How was it adjusted? 0 Loose 0 Snug 7. Were you wearing a hat or glasses? 0 No 0 Yes - Were they thrown off your head by the accident? 0 No 0 Yes 8. What position.were you seated in (driver's, passenger in front, left rear passenger, etc.)? 9. Please describe the position of your body at the time of the accident (example: slouched forward slightly, head turned to right, left ann out the window, right hand OD the steering wheel) 10. Were your brakes on at the time of impact? 0 No 0 Yes 11. Were you aware of the impending collision? 0 No 0 Yes 12. Please describe what happened during the accident (example: head was whipped backwards hitting head rest, then I was thrown forward, right knee hit 'stick shift) 13. Did your head strike any part of your vehicle or any other objects during the accident? D No Dyes - Please describe

3 14. Were you knocked unconscious? D No Dyes - How long? 15. Please describe any other contact you made at the time of the accident (example: 'right knee cut dashboard) If bicycle or motorcycle, describe what you struck and your body position......!' 16. Did you receive any broken bones, cuts, bruises or abrasions (skinned elbows, knees)? 0Nb 0Yes - Please describe. " 17. How many people were in your vehicle? 18. Please describe briefly their injuries as you know them. 19. How did you have your seat back adjusted? 0 Straight up (90 degrees) D Slightly inclined (15 degrees) 0 Inclined (20 degrees) 20. Was your seat damaged by the accident? D No Dyes - Please describe 21. Was your steering wheel damaged by the accident? 0 No 0 Yes' - Please describe l 22. Was your stick shift damaged by the accident? 0 No 0Yes - Please describe 23. Please describe any other damage which occurred INSIDE your vehicle. 24. Were any windows broken by the accident? 0 No Dyes - Please describe 25. How many people were in the vehicle that struck you or you struck? 26. Were any of them injured? 0 No 0 Yes - Were there any fatalities? 0 No 0 Yes 27. Were police called to the scene? 0 No 0 Yes - Did they file a report? 0 No 0 Yes 28. Did you get the license numbers of the other vehicles? 0No 0 Yes

4 29. Did you get insurance infonnation from drivers of the other vehicles involved? 0 No 0 Yes 30. Was this a hit and run? 0 No 0 Yes. AFTER THE ACCIDENT 1. Please describe how you felt immediately after the accident (upset, shocked, stunned, OK, neck or back pain, etc.) 1. How did you leave the accident scene? 0 In my car 0 by ambulance 0 other (cab, friend,etc) 2. Were you taken to a hospital? 0 No 0 Yes - Which one? 3. Name(s) of doctor(s) who attended you there 4. Were X-rays taken there? 0 No 0 Yes - 'What areas? 5. Did you receive any medications, stitches, bandages, shots, braces, collars, etc.? 0 No 0 Yes - Please describe. 6. Was any surgery perfonned? 0 No 0 Yes - Please describe 7. How long were you in the hospital? 8. Whatwasthediagnos~? 9. Were you told to see any other ~octors? 0 No 0 Yes 10. Were any recommendations made for rest, ice, heat, physical therapy, time off of work, etc? 0 No 0 Yes P1easedescribe' 11. Please describe how you felt the next day. 12. Please describe how you felt the next week. 13. Please describe any normal activities which you could not perfonn as a result of the accident (work, sleep, jog)

5 14. Have you lost time from work asa result of the accident? 0 No 0 Yes - How much? 15. Please describe your problems Which resulted from the accident as they are TODAY. (Do not describe areas that have now healed or recovered. " 16. Please describe normal activities which you cannot perform TODAY as a result of the accident. 17. Please describe ON THE NEXT page each area of your current pain separately using the following format: ( Start with the most serious complaint.) Frequency, severity, description, area of pain, radiation, aggravated by, relieved by. DEFINITIONS Frequency: Occasional Intermittent Frequent Constant 25% of the time or less 50% of the time 75% of the time 100% of the time Severity: Mild Slight Moderate Severe only a nuisance, causes a slight handicap causes s marked handicap unable to work Descrip~on: Radiation: Dull ache; sharp, stabbing pain; burning; cramping; pains and needles; numbness; etc. Down the arm (left or right or both) Into fingers Across shoulder (left or right or both) To shoulder blade (left or right or both) To buttocks (left or right or both) To thighs (back, front, left or right or both) To lower leg (back, front, left or right or both) To feet (top, bottom, left or right or both) To toes (top, bottom, left or right or both) Aggravated by: Describe which activities or positions make condition worse, such as prolonged sitting, walking, driving, working at computer, sleeping, etc. Relieved by: Describe what brings some measure of relief such as rest, ice, heat, sleep, aspirin, other drugs, exercise, stretching, chiropractic care, physical therapy. EXAMPLE ON THE NEXT PAGE

6 e-, ;:~ ~.~'.<':~"~i;' f,:',' ",.il)f~(~),;~:u>'h.l"~~;f~'~~i.!~~l~~jp.~~ "V:!}:',: :: ::<:' ; skw!.~~ting to Ore :topof the Ii~a.,whiclj;are qgrava~a bywo'rldijat the computer, bright lights and relieved by asprin (radiation)" (aggravated by) (relieved by) and rest. 2. Constant, slight numbness in the right thumb which is not radiating and becomes worse with work- (frequency, severity,. description) (area) (radiation). iog with the hands at work and is relieved by shaking my hands or by hot water. (aggravated by) (relieved by) 18. Please mark the areas oc pain, nrbness, tingling or pricking you are presently experiencing. ~ = Pain CJ = Numbness ~ = Tingling Pricking or

7 19. Please describe any other significant effects this accident has had on you. 20. How do you feel your condition has improved? -.;..' What kinds of exercise do you regularly perfonn now? 22. Please list in ORDER all doctors or therapists you have seen or been treated by AS A RESULT OF THE ACCIDENT. EXAMPLE: 1. Dr. Smith, a neurologist, January 3, Perfonned Cat Scan. Diagnosed a herniated disc. (doctor) (specialty) (date) (tests done) (diagnosis) Referred me to Dr. Jones. (treatment) 2. Dr. Jones, Chiropractor, January 9, 1986 thru February 20, Took x-rays. Same diagnosis. Treated (doctor) (specialty) (dates) (tests) (diagnosis) 3 times a week for 3 weelis then 2 times a week for 2 weeks with ultrasound & manipulation & gave exercises. (treatment)

8 PASl' MEDICAL msroar 1. Have you ever served in the military? 0 No 0 Yes - During what time frame.." 2. Were you ever buured in the military? 0 No 0 Yes - Please describe injuries and any resulting disabilities. 3. Have you ever had any significant sports il\iuries in the past? 0 No 0 Yes - Please describe including year and any residual disability. ~ 4. Have you ever had any significant on the job injuries in the past? 0 No 0 Yes - Please describe including year and any residual disability S. Were you given any awards for permanent total or permanent partial disability? 0 No 0 Yes - Please describe. 6. Were you given any work restrictions or job changes (vocational rehabilitation)? 0 No 0 Yes - Please describe. 7. Have you had any auto or other accidents in the past? 0 No 0 Yes - Please describe dates, injuries, doctors seen, treatment given and any residu~ disabilities Do you have any other medical problems such as diabetes, cancer, heart or hereditary disorders, etc.? 0 No 0 Yes Pleasedescribe. 9. Have you had any surgeries in the past other than minor surgery? 0 No 0 Yes - Please describe. 10. Are you currently taking any medication such as contraceptives, insulin, heart medication, antibiotics? 0 No 0 Yes Please describe.

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