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Patient Basic Information Personal Information: Last Name: First Name: Mid. Init.: Address: City, State, Zip: Home Phone: Work Phone: Social Security No.: Date of Birth: Date of Injury/Onset: Dominant Hand: Right Left Both Insurance Information: Policy Holder (if different than patient): Policy No.: Special Note: If your injury involved a motor vehicle, skip to page 2. Otherwise, use the spaces below to fully describe your accident, injury or onset, slip and fall, etc. 1. Description of Accident/Injury/Onset Enter a full description of the accident, injury or onset in the space below. 2. Your condition during and immediately after injury/onset Enter the details of your condition during and immediately after your injury/onset. 1

1. Your vehicle type 2. Your position in vehicle 3. What was your vehicle doing at the time of the accident? Car Station Wagon Driver Front Passenger Stopped at intersection Stopped in traffic Stopped at light Van Pickup Truck Left Rear Passenger Making a right turn Making a left turn Parking Large Truck Bus Right Rear Passenger Proceeding along Slowing down Accelerating Other Other Other 4. Time/Speed/Damage 5. Details of Accident 6. Road conditions Time of accident Visibility at time of accident Road conditions at time of accident Your vehicle's Poor Fair Good Icy Wet Sandy Dark Clean and dry speed: mph Their vehicle's Who hit who/what? Point of impact speed: mph You hit other vehicle Head-On Left Front Right Front Damage to your vehicle Other vehicle hit you Read-End Left Rear Right Rear Mild Moderate You hit...(object) Totaled 7. Body Position, etc. Did you see the accident coming: Yes No Does your vehicle have headrests? Yes No Were you braced for the impact? Yes No What was the position of your headrest at the time of the impact? Did you have a seat belt on? Yes No Even with top of head Even with bottom of head Middle of neck Did you have a shoulder harness on? Yes No What was the direction of your head at the time of the impact? Facing straight forward Turned to the right Turned to the left Did driver side air bags deploy? Yes No Did passenger side airbags deploy? Yes No Did side airbags deploy? Yes No 8. Additional accident information Automobile Accident Description Please answer the questions below. If you do not know the answer to any of the questions, do not answer that question. In the case of a motor vehicle accident, enter any additional information here that is not covered by the above check offs. 9. During the accident: 10. After the accident: Did your body strike the inside of your vehicle? Yes No Check off your symptoms right after and a few days following: If yes, describe: Headache Dizziness Mid back pain Cold hands Did you lose consciousness during the injury? Yes No Neck pain Nausea Low back pain Cold feet If yes, for how long? Neck stiffnes Confusion Nervousness Diarrhea Your vehicle's estimated damage? Fainting Fatigue Loss of taste Depression Damage to their vehicle: Mild Moderate Totaled Ringing in ears Tension Toe numbness Anxious Did police show up at the scene? Yes No Loss of smell Irritability Constipation Chest Pain Was an accident report filled out? Yes No Pain behind eyes Shortness of breath Sleeping problems Others: 11. Emergency Room? 12. Treatment History: Where did you go after the accident? Fill in any other doctor(s) seen prior to your first visit to this office. Home Work Hospital ER Private Doctor 1. Dr. First visit date: / / How did you get there? Specialty: X-rays done? Yes No Drove self Somebody else Ambulance Police Types of treatments received: Were X-rays done? Yes No Was lab work done? Yes No How many treatments received? Currently treating? Yes No Body parts X-rayed? Did treatments benefit you? Yes No What lab work? Last visit date: / / The X-rays revealed: 2. Dr. First visit date: / / Treatments: Cervical Collar Ice Other: Types of treatments received: Medications: How many treatments received? Currently treating: Yes No Follow-up instructions: Did treatments benefit you? Yes No Last visit date: / / 2

Description of Symptoms (Describe your symptoms in the sections below, in the order of severity, if possible.) I. First Current Symptom: (Please check off the boxes below to describe your first symptom. Describe only ONE symptom per Section ). Headaches L R B Front of Head Dull Sharp Aching Cutting Throbbing Burning Numbing Tingling Cramping Top of Head Back of Head Spasm Stinging Shooting Pounding Constricting Jaw L R B Eye L R B Up to 1/4 of awake time 1/4 to 1/2 of time Neck L R B 1/2 to 3/4 of awake time Most all the time In the A.M. Upper Back L R B In the P.M. Mid Back L R B 4. Pain Intensity (How it affects your daily activites) Bending forward Low Back L R B Doesn't affect Somewhat affects Bending back Chest L R B Seriously affects Prevents activities Bending left Abdomen L R B Bending right Ribs L R B Twisting left Buttocks L R B Twisting right Head Shoulder L R B Coughing Neck Upper Arm L R B Sneezing Shoulder Forearm L R B Straining Arm Hand L R B Standing Hand Hip L R B Sitting Hip Leg L R B Lifting Leg Foot L R B Foot II. Second Current Symptom: (Please check off the boxes below to describe your next symptom). Headaches L R B Dull Sharp Aching Cutting Front of Head Throbbing Burning Numbing Tingling Cramping Top of Head Spasm Stinging Shooting Pounding Constricting Back of Head Jaw L R B Up to 1/4 of awake time 1/4 to 1/2 of time Eye L R B 1/2 to 3/4 of awake time Neck L R B Most all the time In the A.M. In the P.M. Upper Back L R B 4. Pain Intensity (How it affects your daily activites) Bending forward Mid Back L R B Low Back L R B Doesn't affect Somewhat affects Bending back Seriously affects Prevents activities Bending left Chest Abdomen L R B L R B Ribs L R B Buttocks Shoulder L R B L R B Upper Arm L R B Forearm Hand L R B L R B Hip L R B Leg Foot L R B L R B III. Third Current Symptom: 1. Check only one body location below Headaches L R B Front of Head Top of Head Back of Head Jaw L R B Eye Neck L R B L R B Upper Back L R B Mid Back Low Back L R B L R B Chest L R B Abdomen Ribs L R B L R B Buttocks L R B Shoulder Upper Arm L R B L R B Forearm L R B Hand Hip L R B L R B Leg L R B Foot L R B Head Neck Shoulder Arm Hand Hip Leg Foot 3 Bending right Twisting left Twisting right Coughing Sneezing Straining Standing Sitting Lifting (Please check off the boxes below to describe your 3rd symptom). 2. Types of pain Other types of pain: Dull Sharp Aching Cutting Throbbing Spasm Burning Stinging Numbing Shooting Tingling Pounding Cramping Constricting Up to 1/4 of awake time 1/4 to 1/2 of time 1/2 to 3/4 of awake time Most all the time In the A.M. In the P.M. 4. Pain Intensity (How it affects your daily activites) Bending forward Doesn't affect Somewhat affects Bending back Seriously affects Prevents activities Bending left Bending right Twisting left Head Twisting right Neck Coughing Shoulder Sneezing Arm Straining Hand Standing Hip Sitting Leg Lifting Foot Brings On Aggravates Relieves

Description of Symptoms (Describe your symptoms in the sections below, in the order of severity, if possible.) IV. Fourth Symptom: (Please check off the boxes below to describe your 4th symptom. Describe only ONE symptom per Section ). Headaches L R B Front of Head Dull Sharp Aching Cutting Top of Head Throbbing Burning Numbing Tingling Cramping Back of Head Spasm Stinging Shooting Pounding Constricting Jaw L R B Eye L R B Up to 1/4 of awake time 1/4 to 1/2 of time Neck L R B 1/2 to 3/4 of awake time Most all the time In the A.M. Upper Back L R B In the P.M. Mid Back L R B 4. Pain Intensity (How it affects your daily activites) Bending forward Low Back L R B Doesn't affect Somewhat affects Bending back Chest L R B Seriously affects Prevents activities Bending left Abdomen L R B Bending right Ribs L R B Twisting left Buttocks L R B Twisting right Head Shoulder L R B Coughing Neck Upper Arm L R B Sneezing Shoulder Forearm L R B Straining Arm Hand L R B Standing Hand Hip L R B Sitting Hip Leg L R B Lifting Leg Foot L R B Foot V. Fifth Current Symptom: (Please check off the boxes below to describe your 5th symptom). Headaches L R B Dull Sharp Aching Cutting Front of Head Throbbing Burning Numbing Tingling Cramping Top of Head Spasm Stinging Shooting Pounding Constricting Back of Head Jaw L R B Up to 1/4 of awake time 1/4 to 1/2 of time Eye L R B 1/2 to 3/4 of awake time Most all the time In the A.M. Neck L R B In the P.M. Upper Back L R B 4. Pain Intensity (How it affects your daily activites) Bending forward Mid Back L R B Doesn't affect Somewhat affects Bending back Low Back L R B Chest L R B Seriously affects Prevents activities Bending left Abdomen L R B Ribs Buttocks L R B L R B Shoulder L R B Upper Arm Forearm L R B L R B Hand L R B Hip Leg L R B L R B Foot L R B Head Neck Shoulder Arm Hand Hip Leg Foot Bending right Twisting left Twisting right Coughing Sneezing Straining Standing Sitting Lifting VI. Sixth Current Symptom: (Please check off the boxes below to describe your 6th symptom). Headaches L R B Dull Sharp Aching Cutting Front of Head Throbbing Burning Numbing Tingling Cramping Top of Head Spasm Stinging Shooting Pounding Constricting Back of Head Jaw L R B Eye L R B Up to 1/4 of awake time 1/4 to 1/2 of time Neck L R B 1/2 to 3/4 of awake time Most all the time In the A.M. Upper Back L R B In the P.M. Mid Back L R B 4. Pain Intensity (How it affects your daily activites) Bending forward Low Back L R B Doesn't affect Somewhat affects Bending back Chest L R B Seriously affects Prevents activities Bending left Abdomen L R B Bending right Ribs L R B Twisting left Buttocks L R B Head Twisting right Shoulder L R B Neck Coughing Upper Arm L R B Shoulder Sneezing Forearm L R B Arm Straining Hand L R B Hand Standing Hip L R B Hip Sitting Leg L R B Leg Lifting Foot L R B Foot 4

Description of Symptoms (Describe your symptoms in the sections below, in the order of severity, if possible.) VII. Seventh Symptom: (Please check off the boxes below to describe your 7th symptom. Describe only ONE symptom per Section ). Headaches L R B Front of Head Dull Sharp Aching Cutting Top of Head Throbbing Burning Numbing Tingling Cramping Spasm Stinging Shooting Pounding Constricting Back of Head Jaw L R B Eye L R B Up to 1/4 of awake time 1/4 to 1/2 of time Neck L R B 1/2 to 3/4 of awake time Most all the time In the A.M. Upper Back L R B In the P.M. Mid Back L R B 4. Pain Intensity (How it affects your daily activites) Bending forward Low Back L R B Doesn't affect Somewhat affects Bending back Chest L R B Seriously affects Prevents activities Bending left Abdomen L R B Bending right Ribs L R B Twisting left Buttocks L R B Twisting right Head Shoulder L R B Coughing Neck Upper Arm L R B Sneezing Shoulder Forearm L R B Straining Arm Hand L R B Standing Hand Hip L R B Sitting Hip Leg L R B Lifting Leg Foot L R B Foot VIII. Eighth Current Symptom: (Please check off the boxes below to describe your 8th symptom). Headaches L R B Dull Sharp Aching Cutting Front of Head Throbbing Burning Numbing Tingling Cramping Top of Head Spasm Stinging Shooting Pounding Constricting Back of Head Jaw L R B Up to 1/4 of awake time 1/4 to 1/2 of time Eye L R B 1/2 to 3/4 of awake time Neck L R B Most all the time In the A.M. In the P.M. Upper Back L R B 4. Pain Intensity (How it affects your daily activites) Bending forward Mid Back L R B Low Back L R B Doesn't affect Somewhat affects Bending back Seriously affects Prevents activities Bending left Chest L R B Abdomen Ribs L R B L R B Buttocks L R B Shoulder Upper Arm L R B L R B Forearm L R B Hand Hip L R B L R B Leg L R B Foot L R B IX. Ninth Current Symptom: 1. Check only one body location below Headaches L R B Front of Head Top of Head Back of Head Jaw L R B Eye L R B Neck Upper Back L R B L R B Mid Back L R B Low Back Chest L R B L R B Abdomen L R B Ribs Buttocks L R B L R B Shoulder L R B Upper Arm Forearm L R B L R B Hand L R B Hip Leg L R B L R B Foot L R B Head Neck Shoulder Arm Hand Hip Leg Foot Bending right Twisting left Twisting right Coughing Sneezing Straining Standing Sitting Lifting (Please check off the boxes below to describe your 9th symptom). 2. Types of pain Other types of pain: Dull Sharp Aching Cutting Throbbing Burning Numbing Tingling Cramping Spasm Stinging Shooting Pounding Constricting Up to 1/4 of awake time 1/4 to 1/2 of time 1/2 to 3/4 of awake time Most all the time In the A.M. In the P.M. 4. Pain Intensity (How it affects your daily activites) Bending forward Doesn't affect Somewhat affects Bending back Seriously affects Prevents activities Bending left Bending right Twisting left Head Twisting right Neck Coughing Shoulder Sneezing Arm Straining Hand Standing Hip Sitting Leg Lifting Foot 5

Activities of Daily Living Assessment Rate your current difficulties, resulting from your accident/illness, with regard to the various activities listed below. Use the following 1 to 5 scale and WRITE IN THE APPROPRIATE NUMBER that most closely describes your current degree of difficulty: 1 = "I can do it without any difficulty", 2 = "I can do it without much difficulty, despite some pain", 3 = "I manage to do it by myself, despite marked pain", 4 = "I manage to do it, despite the pain, but only if I have help", 5 = "I cannot do it at all, because of the pain". NOTE: Only fill in areas that are affected. Difficulties with Self Care and Personal Hygiene Activities Bathing... Drying hair... Brushing teeth... Putting on shoes... Preparing meals... Taking out trash.. Showering... Combing hair... Making bed... Tying shoes... Eating... Doing laundry... Washing hair.. Washing face... Putting on shirt... Putting on pants... Cleaning dishes... Going to toilet... Difficulties with Physical Activities Standing... Walking... Kneeling... Bending back... Twisting left... Leaning back... Sitting... Stooping... Reaching... Bending left... Twisting right... Leaning left... Reclining... Squatting... Bending forward.. Bending right... Leaning forward... Leaning right... Standing for long periods... Sitting for long periods... Walking for long periods... Kneeling for long periods... Difficulties with Functional Activities Carrying small objects... Lifting weights off floor... Pushing things while seated... Carrying large objects... Lifting weights off table... Pushing things while standing.. Carrying brief case... Climbing stairs... Pulling things while seated... Carrying large purse... Climbing inclines... Pulling things while standing... Exercising upper body... Exercising lower body... Exercising arms... Exercising legs... Difficulties with Social and Recreational Activities Bowling... Jogging... Swimming... Ice Skating... Competitive Sports. Dating... Golfing... Dancing... Skiing... Roller Skating... Hobbies... Dining out... Difficulties with Travelling Driving a motor vehicle... Riding as a passenger in a motor vehicle... Riding as a passenger on a train... Driving for long periods of time... Riding as a passenger on an airplane... Riding as a passenger for long periods... Use the following 1 to 5 scale to describe the difficulties below: 1 = "This area is not affected by my condition", 2 = "This area is slightly affected by my condition", 3 = "My condition moderately restricts my ability in this area", 4 = " My condition seriously limits my ability in this area", 5 = "My condition prevents me from using this ability" Difficulties with Different Forms of Communication Concentrating... Hearing... Listening... Speaking... Reading... Writing... Using a keyboard... Difficulties with the Senses Seeing... Hearing... Sense of touch... Sense of taste... Sense of smell... Difficulties with Hand Functions Grasping... Holding... Pinching... Percussive movements... Sensory discrimination... Difficulties with Sleep and Sexual Function Being able to have normal, restful nights sleep... Being able to participate in desired sexual activity... Write in below any additional information regarding your Activities of Daily Living (that wasn't covered above): Prior Symptom History Prior Similar Symptoms Has your History Contributed to your Current Symptoms? I have NOT had prior symptoms similar to my current complaints. My history HAS contributed to my current symptoms. My current complaints DID exist before, but have not been bothering me. My history HAS NOT contributed to my current symptoms. My current complaints ALREADY existed and were worsened. I 'm NOT SURE if my history has contributed to my current symptoms. My most recent prior similar symptoms (if applicable) occured... months ago / years ago Or on Date: / / Write in below any other Prior Symptom History, not covered above: 6

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