AUTO ACCIDENT INFORMATION - Blue Poppy
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? ______________________________________________________
18. Were you able to get out of the car under your own power or did you have to be assisted? ___________________________________________________________
19. Were you taken to a hospital emergency room? _____________________________
20. Who took you to the hospital? __________________________________________
21. Were you examined at the hospital in the emergency room? __________________
22. In your opinion, was the examination thorough? ____________________________
23. Did you have x-rays taken? ____________________________________________
24. What did they tell you about your X-Ray? ________________________________
25. When did you first begin to feel headaches? _______________________________
26. Are the headaches mild, moderate or severe? ______________________________
27. Are the headaches constant, daily or do they come and go? ___________________
28. Do you have pulsating, sharp pain or pressure? _____________________________
29. Since the accident, have you had any dizzy spells? __________________________
30. Do you have any buzzing or ringing in the ears? ____________________________
31. Do you have blurring of the eyes? _______________________________________
32. Does light bother your eyes? ___________________________________________
33. Have you noticed any changes in your ability to remember, concentrate or think clearly since the accident? _____________________________________________
34. Have you been more irritable? __________________________________________
35. Have you been more nervous? __________________________________________
36. Have you been depressed at all (the blues)? _______________________________
37. How have you been sleeping? __________________________________________
38. Tell me about your energy level? ________________________________________
39. Tell me about your neck pain? __________________________________________
40. Is your neck pain mild, moderate or severe? _______________________________
41. Is your neck pain constant, daily or does it come and go? _____________________
42. Is your neck pain sharp, a dull ache or burning? ____________________________
43. Have you noticed that you are restricted looking over your shoulder at time? _____
44. Do you have any pain that goes down your arms? __________________________
45. Do you have any numbness in your hands? ________________________________
46. Do you have any upper back pain? _______________________________________
47. Is the pain mild, moderate or severe? _____________________________________
48. Is the pain constant, daily or does it come and go? __________________________
49. Is the pain sharp, a dull ache or burning? __________________________________
50. Do you have any pain down your legs? ___________________________________
51. Do you have any abdominal pain? _______________________________________
52. Have you ever been in an auto accident before? ____________________________
53. If yes, what was the date? ______________________________________________
54. Prior to this accident, did you ever have any headaches, neck pain, back pain, arm pain or leg pain? _____________________________________________________
55. Have you ever been seriously ill? ________________________________________
56. Have you ever been hospitalized? _______________________________________
57. How is this affecting you at home? ______________________________________
58. How is this affecting you at work? _______________________________________
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