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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