Auto Accident Information

AUTO ACCIDENT INFORMATION

(To be completed by PI patient)

Patient name: ______Date: ______

Date of accident: ______

1. Tell about your accident ______

2. When did the accident happen? ______

3. Where did the accident happen? ______

4. How fast was the car going that hit you? ______

5. What kind of car hit you? ______

6. Were you in the car by yourself? ______

7. Did you have your safety belt on? ______

8. Does your care have a head restraint? ______

9. Was the head restraint positioned in the middle, approximately 2 inches away? ______

10. To the best of your knowledge, what happened to your body at the time of impact during the accident? ______

11. Did your head whip backward and forward forcefully? ______

12. Did you hear any popping, cracking, or snapping noises in your neck? ______

13. Did you have any immediate pain after the accident? ______

14. Did any parts of your body strike part of the car? (knees, left arm, chest, head) ______

15. Do you or did you have any bruises? ______

16. Were you rendered unconscious? ______

17. Were you stunned? ______

1. Were you able to get out of the car under your own power or did you have to be assisted? ______

1. Were you taken to a hospital emergency room? ______

1. Who took you to the hospital? ______

1. Were you examined at the hospital in the emergency room? ______

1. In your opinion, was the examination thorough? ______

1. Did you have x-rays taken? ______

1. What did they tell you about your X-Ray? ______

1. When did you first begin to feel headaches? ______

1. Are the headaches mild, moderate or severe? ______

1. Are the headaches constant, daily or do they come and go? ______

1. Do you have pulsating, sharp pain or pressure? ______

1. Since the accident, have you had any dizzy spells? ______

1. Do you have any buzzing or ringing in the ears? ______

1. Do you have blurring of the eyes? ______

1. Does light bother your eyes? ______

1. Have you noticed any changes in your ability to remember, concentrate or think clearly since the accident? ______

1. Have you been more irritable? ______

1. Have you been more nervous? ______

1. Have you been depressed at all (the blues)? ______

1. How have you been sleeping? ______

1. Tell me about your energy level? ______

1. Tell me about your neck pain? ______

1. Is your neck pain mild, moderate or severe? ______

1. Is your neck pain constant, daily or does it come and go? ______

1. Is your neck pain sharp, a dull ache or burning? ______

1. Have you noticed that you are restricted looking over your shoulder at time? _____

1. Do you have any pain that goes down your arms? ______

1. Do you have any numbness in your hands? ______

1. Do you have any upper back pain? ______

1. Is the pain mild, moderate or severe? ______

1. Is the pain constant, daily or does it come and go? ______

1. Is the pain sharp, a dull ache or burning? ______

1. Do you have any pain down your legs? ______

1. Do you have any abdominal pain? ______

1. Have you ever been in an auto accident before? ______

1. If yes, what was the date? ______

1. Prior to this accident, did you ever have any headaches, neck pain, back pain, arm pain or leg pain? ______

1. Have you ever been seriously ill? ______

1. Have you ever been hospitalized? ______

1. How is this affecting you at home? ______

1. How is this affecting you at work? ______