Auto Accident/Personal Injury Information
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- Priscilla Thomas
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1 Auto Accident/Personal Injury Information Patient s Name: Today s Date: Personal Injury Information Date of Accident: Time of Accident: am/pm Did police arrive on scene? [ ] Yes [ ] No Is there a report? [ ] Yes [ ] No Your Vehicle: Year- Make- Model- Was your foot on the brake? [ ] Yes [ ] No Speed at impact- mph Was your vehicle: [ ] Stopped [ ] Decelerating [ ] Accelerating [ ] Moving Steady mph Other Vehicle: Year- Make- Model- Was the vehicle: [ ] Decelerating [ ] Accelerating [ ] Moving Steady, at mph Were you hospitalized? [ ] Yes [ ] No What hospital? How were you transported? What treatment did you receive? [ ] X-ray [ ] MRI [ ] CT scan: What area? Bleeding/Cuts? [ ] Yes [ ] No Where? Bruises? [ ] Yes [ ] No Where? Were you aware/surprised at impact? [ ] Aware [ ] Surprised Were you wearing a seatbelt? [ ] Yes [ ] No Type: [ ] Lap belt [ ] Shoulder-Lap belt Did you hit any part of the vehicle? [ ] Yes [ ] No What part/where? What symptoms did you have immediately after the accident? What symptoms do you currently have? Where did your vehicle sustain damage? What is the estimated cost of damages? Was your head pointing straight ahead? [ ] Yes [ ] No, which direction? Was your trunk pointing straight ahead [ ] Yes [ ] No, which direction? Has Fault Been Established? [ ] Yes [ ] No, [ ] Yours [ ] Others YOUR Insurance: Adjustor: Ph: OTHER Insurance: Adjustor: Ph: Attorney: Ph: Claim/Case Number: Please describe what happened during the accident: 3715 East Overland Road Suite 105 Meridian, Idaho Phone: Fax: Dr. Suzi Cunningham, D.C., C.S.C.S. Dr. Travis Cunningham, D.C., C.S.C.S.
![[ ] Yes [ ] No Speed at impact- mph Was your vehicle: [ ] Stopped [ ] Decelerating [ ] Accelerating [ ] Moving Steady mph Other Vehicle: Year- Make- Model- Was the vehicle: [ ] Decelerating [ ]](/docs-images/56/7969474/images/page_1.jpg "Accelerating [ ] Moving Steady, at mph Were you hospitalized? [ ] Yes [ ] No What hospital? How were you transported? What treatment did you receive? [ ] X-ray [ ] MRI [ ] CT scan: What area?")
2 Work Accident Injury Information Patient s Name: Today s Date: Work Injury Information Name of Employer: Claim Number: Insurance Company: Insurance Adjustor: Phone: Date Filed: Date of Injury: Were you hospitalized? [ ] Yes [ ] No if yes, where? How were your transported? What treatment did you receive? [ ] X-ray [ ] MRI [ ] CT scan: What area? Did you receive any medication? [ ] Yes [ ] No If yes, please list; What types of injuries did you sustain (cuts/bruises/fractures/sprains/etc.)? What symptoms did you feel immediately after the accident? What symptoms do you currently feel? Attorney (if applicable): Phone: Please describe what happened during the accident: 3715 East Overland Road Suite 105 Meridian, Idaho Phone: Fax: Dr. Suzi Cunningham, D.C., C.S.C.S. Dr. Travis Cunningham, D.C., C.S.C.S.
![[ ] Yes [ ] No If yes, please list; What types of injuries did you sustain (cuts/bruises/fractures/sprains/etc.)? What symptoms did you feel immediately after the accident?](/docs-images/56/7969474/images/page_2.jpg "What symptoms do you currently feel? Attorney (if applicable): Phone: Please describe what happened during the accident: 3715 East Overland Road Suite 105 Meridian, Idaho 83642 Phone: 208.888.")
3 Roland Morris Acute Low Back Pain Disability Questionnaire Name: (Please Print) Date: Age: Date of Birth: Occupation: How long have you had low back pain? years Is this your first episode of low back pain? yes months weeks no Use the letters below to indicate the type and location of your sensations right now. (Please remember to complete both sides of this form.) A = Ache B = Burning N = Numbness P = Pins and needles S = Stabbing O = Other Over Please
4 ROLAND MORRIS ACUTE LOW BACK PAIN DISABILITY QUESTIONNAIRE Name: Date: / / Please Read Instructions: When your back hurts, you may find it difficult to do some of the things you normally do. Mark only the sentences that describe you today. gfedc I stay at home most of the time because of my back. gfedc I change position frequently to try to get my back comfortable. gfedc I walk more slowly than usual because of my back. gfedc Because of my back, I am not doing any jobs that I usually do around the house. gfedc Because of my back, I use a handrail to get upstairs. gfedc Because of my back, I lie down to rest more often. gfedc Because of my back, I have to hold on to something to get out of an easy chair. gfedc Because of my back, I try to get other people to do things for me. gfedc I get dressed more slowly than usual because of my back. gfedc I only stand up for short periods of time because of my back. gfedc Because of my back, I try not to bend or kneel down. gfedc I find it difficult to get out of a chair because of my back. gfedc My back is painful almost all of the time. gfedc I find it difficult to turn over in bed because of my back. gfedc My appetite is not very good because of my back. gfedc I have trouble putting on my socks (or stockings) because of the pain in my back. gfedc I can only walk short distances because of my back pain. gfedc I sleep less well because of my back. gfedc Because of my back pain, I get dressed with the help of someone else. gfedc I sit down for most of the day because of my back. gfedc I avoid heavy jobs around the house because of my back. gfedc Because of back pain, I am more irritable and bad tempered with people than usual. gfedc Because of my back, I go upstairs more slowly than usual. gfedc I stay in bed most of the time because of my back. With Permission: Roland M, Morris R. A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain. Spine 1983 Mar;8(2):141-4.
5 NECK DISABILITY INDEX QUESTIONNAIRE Name: Date: / / Please Read: This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage everyday activities. Please answer each section by selecting the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but Please just select the one choice which closely describes your problem right now. SECTION 1 - Pain Intensity gfedc A. I have no pain at the moment. gfedc B. The pain is mild at the moment. gfedc C. The pain comes and goes and is moderate. The pain is moderate and does not vary much. gfedc E. The pain is severe but comes and goes. gfedc F. The pain is severe and does not vary much. SECTION 2 - Personal Care gfedc A. I can look after myself without causing extra pain. gfedc B. I can look after myself normally but it causes extra pain. gfedc C. It is painful to look after myself and I am slow and careful. I need some help, but manage most of my personal care. gfedc E. I need help every day in most aspects of self-care. gfedc F. I don not get dressed, I wash with difficulty and stay in bed. SECTION 3 - Lifting gfedc A. I can lift heavy weights without extra pain. gfedc B. I can lift heavy weights, but it causes extra pain. gfedc C. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, e.g. on the table. Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. gfedc E. I can lift very light weights. gfedc F. I cannot lift or carry anything at all. SECTION 4 - Reading gfedc A. I can read as much as I want to with no pain in my neck. gfedc B. I can read as much as I want with slight pain in my neck. gfedc C. I can read as much as I want with moderate pain in my neck. I cannot read as much as I want because of moderate pain in my neck. gfedc E. I cannot read as much as I want because of severe pain in my neck. gfedc F. I cannot read at all. SECTION 5 - Headache gfedc A. I have no headaches at all. gfedc B. I have slight headaches which come infrequently. gfedc C. I have moderate headaches which come infrequently. I have moderate headaches which come frequently. gfedc E. I have severe headaches which come frequently. gfedc F. I have headaches almost all the time. SECTION 6 - Concentration gfedc A. I can concentrate fully when I want to with no difficulty. gfedc B. I can concentrate fully when I want to with slight difficulty. gfedc C. I have a fair degree of difficulty in concentrating when I want to. I have a lot of difficulty in concentrating when I want to. gfedc E. I have a great deal of difficulty in concentrating when I want to. gfedc F. I cannot concentrate at all. SECTION 7 - Work gfedc A. I can do as much work as I want to. gfedc B. I can only do my usual work, but no more. gfedc C. I can do most of my usual work, but no more. I cannot do my usual work. gfedc E. I can hardly do any work at all. gfedc F. I cannot do any work at all. SECTION 8 - Driving gfedc A. I can drive my car without neck pain. gfedc B. I can drive my car as long as I want with slight pain in my neck. gfedc C. I can drive my car as long as I want with moderate pain in my neck. I cannot drive my car as long as I want because of moderate pain in my neck. gfedc E. I can hardly drive my car at all because of severe pain in my neck. gfedc F. I cannot drive my car at all. SECTION 9 - Sleeping gfedc A. I have no trouble sleeping. gfedc B. My sleep is slightly disturbed (less than 1 hour sleepless). gfedc C. My sleep is mildly disturbed (1-2 hours sleepless). My sleep is moderately disturbed (2-3 hours sleepless). gfedc E. My sleep is greatly disturbed (3-5 hours sleepless). gfedc F. My sleep is completely disturbed (5-7 hours sleepless). SECTION 10 - Recreation gfedc A. gfedc B. gfedc C. I am able to engage in all recreational activities with no pain in my neck at all. I am able to engage in all recreational activities with some pain in my neck. I am able to engage in most, but not all recreational activities because of pain in my neck. I am able to engage in a few of my usual recreational activities because of pain in my neck. gfedc E. I can hardly do any recreational activities because of pain in my neck. gfedc F. I cannot do any recreational activities at all. Vernon H and Hagino C, 1991 (with permission from Fairbank J)
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