MOTOR VEHICLE ACCIDENT QUESTIONNAIRE
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- Chastity Bell
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1 MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment. NAME: Date of Injury: DATE: Age: Accident Details: 1. What kind of vehicle were you in?: Year - Make - Model - 2. Where were you seated? (circle): Driver / Front passenger / Rear left / Rear right 3. Were you wearing your seat belt? (circle): Yes / No 4. Did the airbags deploy? (circle): Yes / No 5. What was your body position at impact? (circle): -Looking straight / Looking right / Looking left / -Both hands on wheel / Right hand on wheel / Left hand on wheel / Hands in lap -Right foot on brake / Right foot on gas / Left foot on floorboard / Both feet on floorboard 6. Where was the damage to your vehicle?: Front: Driver Side Passenger Side 1
2 7. What kind of vehicle struck you?: 8. If possible, please roughly draw out what happened in the accident: 9. How fast was your vehicle traveling? (approximately): mph 10. How fast was the other vehicle traveling? (approximately): mph 11. Were you prepared for the impact, did you brace yourself? (circle): Yes / No 12. Did you lose consciousness? (circle): Yes / No 2
3 13. Were you in a daze, felt dizzy, disoriented, confused, etc?. (circle): Yes / No a. How long? (ex. couple of seconds, 5 minutes, etc.) ***If you answered YES to either question 12 or 13, please fill out question 13a*** 14. Where did you go for medical treatment?: 15. Were you taken by ambulance? (circle): Yes / No 13a. After a head injury or accident some people experience symptoms which can cause worry or nuisance. We would like to know if you now suffer from any of the symptoms given below. As many of these symptoms occur normally, we would like you to compare yourself now with before the accident. For each one, please circle the number closest to your answer. 0 = Not experienced at all, 1 = No more of a problem, 2 = A mild problem, 3 = A moderate problem, 4 = A severe problem Compared with before the accident, do you now (i.e., over the last 24 hours) suffer from: Headaches Feelings of Dizziness Nausea and/or Vomiting Noise Sensitivity, easily upset by loud noise Sleep Disturbance Fatigue, tiring more easily Being Irritable, easily angered Feeling Depressed or Tearful Feeling Frustrated or Impatient Forgetfulness, poor memory Poor Concentration Taking Longer to Think
4 Blurred Vision Light Sensitivity, Easily upset by bright light Double Vision Restlessness Are you experiencing any other difficulties? (please list) Please take a moment to specifically identify your pain: 4
5 What is your pain level at rest? (circle): NO PAIN WORST PAIN IMAGINABLE What is your pain level with activity? (circle): NO PAIN WORST PAIN IMAGINABLE How would you describe your pain? (circle): Deep-pressure Tightness Spasms Tingling Numbness Pinprick Burning Sharp-shooting Stabbing Is your pain (circle): Constant Intermittent Since the accident, is your pain (circle): Unchanged Worse Better What makes your pain worse? (circle): Activity - Bending / Lifting / Walking / Sitting / What makes your pain better? (circle): Medications / Ice / Heat / Chiropractic / Rest / Do you have any weakness? (circle): Yes / No --- +/or numbness? Yes / No -If yes, where (circle): Left: Arm Leg --- Left: Arm Leg Right: Arm Leg --- Right: Arm Leg Do you have any loss of control or changes of your bowel or bladder? (circle): Yes / No What treatments have you had following this accident? (circle): Physical therapy Heating pad Ice pack Injections Chiropractic Epidural injections Surgery Massage Medications Acupuncture How has this accident affected your life? 5
6 Have you missed work? (circle): Yes / No -If yes, how much: -Have you returned to work?d (circle): Yes / No -Have you EVER been in another motor vehicle, work or any other type of injury? MEDICAL CONDITIONS (Please list: such as diabetes, depression, gastric reflux): MEDICATIONS (Tylenol, ibuprofen, Motrin, Alleve): SURGERIES: ALLERGIES: FAMILY HISTORY: FATHER age, alive ( circle): Yes / No - medical conditions: MOTHER age, alive (circle): Yes / No - medical conditions: SOCIAL HISTORY: Tobacco use (circle): Yes / No Alcohol use (circle): Yes / Social / No Drug use (circle): Yes / No REVIEW OF SYSTEMS: (mark only if positive) General- Skin- Head- Ears- Weight loss or gain Rashes Headache Decreased hearing Fatigue Dryness Head injury Ringing in ears Fever or chills Lumps Earache Eyes- Nose- Neck- Cardiovascular- Glasses or contacts Discharge Lumps Chest pain Blurry or double vision Itching Swollen glands Tightness Flashing lights Nosebleeds Palpitations 6
7 Respiratory- Gastrointestinal- Urinary- Coughing up blood Constipation / Diarrhea Increased Frequency Shortness of breath Change in appetite Incontinence Painful breathing Nausea Blood in urine Musculoskeletal- Neurologic- Psychiatric- Muscle or joint pain Dizziness Nervousness Redness of joints Fainting Depression Swelling of joints Seizures Memory loss Thank you! Office use: 7
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