PATIENT INJURY/MEDICAL HISTORY FORM

Name _________________________________________________________ Date _______________________________

Date of Loss/Onset (Accident): __________________________ Claim Number: __________________________________

Describe Accident:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

Specifics of Accident (Mark each that applies to the accident): Immediately Following the Accident
Job or Work Related injury ( ) Yes ( ) No

Your were the [ ] Driver [ ] Passenger [ ] Ambulance – Paramedics Called

Sitting [ ] Front seat [ ] Back seat [ ] Treated at Scene
[ ] Transported to Hospital by Ambulance
Impending Collision [ ] Braced [ ] Not braced [ ] Went to Hospital on his/her Own
Head Did [ ] Strike Object [ ] Not strike Object [ ] Diagnostics Preformed at Hospital
Did you experience [ ] Shock [ ] Medication Prescribed
[ ] Flash of Light Seen Upon Impact [ ] Treatment at Hospital
[ ] Air bag Deployed [ ] Follow-up Recommended

Time Loss
[ ] NO time loss from work due to injury. I am currently working with No limitations.
[ ] NO time loss form work due to injury BUT I do have limitations*.
[ ] I have experienced time loss from work due to injury. Indicate number of days____, weeks____, months_____ etc
[ ] N/A
Additional Comments:
______________________________________________________________________________________________
______________________________________________________________________________________________
*******************************************************************************************************
Mechanism of Injury
Were you surprised by the impact? __Yes __No
In relation to the back of your head, was your headrest set: __Low __Middle __High __None
Where was your head facing at the time of impact? __Left __Forward __Right __Unknown
Were you leaning forward at the time of impact? __Yes __No
Were you wearing a seatbelt/harness? __Yes __No
Were you rendered unconscious as a result of the accident? __Yes __No
Did you feel pain immediately after the accident? __Yes __No
Year and type of vehicle were you in? _________________________________________________________
Size of your vehicle? __Small __Mid __Large __Unknown
Year and type of other vehicle involved in the accident? ____________________________________________
Size of other vehicle? __Small __Mid __Large __Unknown
What was the approximate speed of your vehicle when the accident occurred? __________________________
What was the approximate speed of the other vehicle when the accident occurred? _______________________

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Patient’s Name: __________________________________________ Date: _________________________

PAIN FORM
Symptomatology Consultation Form

Pain Intensity:
Intensity scale:
0 = No pain
1 – 3 = Mild Nuisance
4 – 5 = Mild to Moderate Nuisance
6 - 7 = Moderate, having trouble dealing with it
8 -10 = Severe, it is affecting patient’s quality of life

WHERE DID YOU HURT BEFORE THE ACCIDENT

Symptoms prior to most recent motor vehicle collision:
Headaches: exactly where/site ______ intensity____ frequency of awake time ______________
Jaw Pain: exactly where/site ______ intensity____ frequency of awake time _____________
Neck Pain: exactly where/site ______ intensity____ frequency of awake time _____________
Middle Back Pain: exactly where/site ______ intensity____ frequency of awake time ______________
Low Back Pain: exactly where/site ______ intensity____ frequency of awake time ______________
Other: exactly where/site ______ intensity____ frequency of awake time ______________
Other: exactly where/site ______ intensity____ frequency of awake time ______________
Other: exactly where/site ______ intensity____ frequency of awake time ______________

WHERE DID YOU HURT IMMEDIATELY AFTER THE ACCIDENT

Original symptoms from most recent motor vehicle collision:
Headaches: exactly where/site ______ intensity____ frequency of awake time ______________
Jaw Pain: exactly where/site ______ intensity____ frequency of awake time _____________
Neck Pain: exactly where/site ______ intensity____ frequency of awake time _____________
Middle Back Pain: exactly where/site ______ intensity____ frequency of awake time ______________
Low Back Pain: exactly where/site ______ intensity____ frequency of awake time ______________
Other: exactly where/site ______ intensity____ frequency of awake time ______________
Other: exactly where/site ______ intensity____ frequency of awake time ______________
Other: exactly where/site ______ intensity____ frequency of awake time ______________

WHERE ARE YOU HURTING TODAY

Presenting/Current Symptoms:
Headaches: exactly where/site ______ intensity____ frequency of awake time ______________
Jaw Pain: exactly where/site ______ intensity____ frequency of awake time _____________
Neck Pain: exactly where/site ______ intensity____ frequency of awake time _____________
Middle Back Pain: exactly where/site ______ intensity____ frequency of awake time ______________
Low Back Pain: exactly where/site ______ intensity____ frequency of awake time ______________
Other: exactly where/site ______ intensity____ frequency of awake time ______________
Other: exactly where/site ______ intensity____ frequency of awake time ______________
Other: exactly where/site ______ intensity____ frequency of awake time ______________

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What makes current pain worse:
Describe directly below Achy Burning Dull Sharp Throb Other
for example (bending, Worse in
sitting) AMorPM
Headaches:
Jaw Pain:
Neck Pain:
Middle Back Pain:
Low Back Pain:
Other:
Other:
Other:

What makes current pain better:

Headaches:
Jaw Pain:
Neck Pain:
Middle Back Pain:
Low Back Pain:
Other:
Other:
Other:

Further Pain information:

Radiating Pain/Numbness/Tingling/Burning/Weakness ____Yes ___No
Location ____________________________________________________________________________

**********************************************************************************************

Social History
List your Hobbies & Exercise Activities__________________
[ ] Single [ ] Smoker __________________
[ ] Married [ ] Non-Smoker __________________
[ ] Divorced [ ] Drinks Alcohol __________________
Number of Children: ______ [ ] Does not drink Alcohol
[ ] Takes Drugs
[ ] Does not take Drugs

Occupational History
Your Employer ________________________________ What is your current job satisfaction:
[ ] Very Satisfied
Job Title ______________________________________ [ ] Satisfied
[ ] Dissatisfied
Are your Job Duties Physically demanding for you? [ ] Yes [ ] No [ ] Very Dissatisfied
Have you had any disability time? [ ] Yes [ ] No
If you are currently working which are you performing? Your highest level of education attained?_________
[ ] Regular Duties
[ ] Limited – Light Duties
*******************************************************************************************************
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Name _________________________________________________________ Date _______________________________

Medical History Form 1

I have seen the following physician/practitioners for this condition: Do you feel you are troubled with:
Chiropractor (Name): _________________________________ [ ] Anxiety
Massage Therapist: ___________________________________ [ ] depression
Neurologist: _________________________________________ [ ] irritability
Orthopedist: _________________________________________
Physical Therapist: ___________________________________
Physician: __________________________________________ Current medications I am taking:
Psychiatrist/Psychologist: ______________________________ ________________________________
Other: _______________________________________________ _________________________________
_________________________________
_________________________________

List the treatments you have had for this condition. Past Surgeries:
[ ] Ice [ ] Chiropractic _________________________________
[ ] Heat/Ultrasound [ ] Osteopathy _________________________________
[ ] Electrical Stimulation [ ] Injections
_________________________________
[ ] Exercises [ ] Acupuncture _________________________________
[ ] Gravity Inversion – Traction [ ] Naturopathy
[ ] Bed Rest [ ] Massage
Past Hospitalizations:

__________________________________

List previous back, neck and musculoskeletal problems:

****************************************************************************************************

Name _________________________________________________________ Date _______________________________

PATIENT INJURY/MEDICAL HISTORY FORM 2

List the types of Diagnostic Testing that has been for this condition:
[ ] X-rays [ ] Discogram
[ ] CT Scan [ ] Bone Scan
[ ] Myelogram [ ] EMG
[ ] MRI

Females – Mark if have the following:

[ ] Vaginal bleeding other than period
[ ] Pap smear within last two years
[ ] Painful menstrual periods
[ ] Back pain with menstrual periods
[ ] Other menstrual problems

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Name _________________________________________________________ Date _______________________________

Mark if you have had any of the following symptoms in the past 5 years:

[ ] Unexplained fevers [ ] Swollen ankles

[ ] Night sweats [ ] Stomach pain
[ ] Weight loss of 10 lbs or more [ ] Change in bowel habits
[ ] Loss of appetite [ ] Persistent diarrhea
[ ] Excessive fatigue [ ] Excessive constipation
[ ] Problems with depression [ ] Dark black stools
[ ] Difficulty sleeping [ ] Blood in stools
[ ] Unusual stress at work [ ] Pain-burning when urinating
[ ] Unusual stress at home [ ] Difficulty urinating – start / stop
[ ] Easy bruising [ ] Blood in urine
[ ] Excessive bleeding [ ] Need to urinate more at night
[ ] Lumps in neck, armpit or groin [ ] Morning stiffness
[ ] Chest pain or tightness [ ] Persistent eye redness
[ ] Persistent or unusual cough [ ] Muscle tenderness
[ ] Trouble breathing with exercise [ ] Dry eyes or mouth
[ ] Trouble breathing lying flat [ ] Skin rashes
[ ] Coughing up blood [ ] Joint pain or swelling

Make sure to fill out the neck pain disability index questionnaire and/ or Oswestry low back pain questionnaire in addition.

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