Head Trauma Case History Form printable pdf download

Head Trauma Case History

Name: ________________________ DOB:____________Age now______ Date______________

Address_________________________________ City________________State_____ Zip________

SSN________________________

referred by____________________________________

Current medications:______________________________________________________________

______________________________________________________________________________

Allergies:_______________________________________________________________________

1. Date of accident/trauma _______________

3. Describe the accident/trauma _____________________________________________________

_______________________________________________________________________________

Type of Accident

3A. Motor Vehicle

Type of vehicle you were in: ____________________________

If other vehicle(s) involved, list type(s) ____________________________

Where were you sitting?

______ Front Seat

______ Left Side

______ Middle

______ Back Seat

______ Right Side

______ Unusual Position

Which restraints were used? (Check all that apply)

______lap

______ shoulder

______car seat

______booster seat

______air bag

Speed of vehicle you were in __________________________________

Speed of other object or vehicle __________________________________

Did your vehicle hit another object?

YES / NO

or did other vehicle hit your vehicle?

YES / NO

If yes, where was your vehicle hit?

______ Head On

______ Toward Front

______ Drivers Side

______ Rear Ended

______ Toward Rear

______ Passenger Side

Did you experience whiplash?

YES / NO

Did you hit your head?

YES / NO

If yes, on what? ___________________________________

3B. Other Accidents

Type (ex Home Industrial Fall Hit by Object ,etc.) ________________________________________________________

Please describe: _____________________________________________________________________________________

__________________________________________________________________________________________________

3C. Toxic

Type (ex: medication related, drug abuse, poison, etc.) _______________________________________________________

Please describe: _____________________________________________________________________________________

__________________________________________________________________________________________________

3D. Anoxic

Type (ex: drowning, C02, anesthesia, cord around neck, etc.) __________________________________________________

Please describe: _____________________________________________________________________________________

__________________________________________________________________________________________________

3E. Vascular

Type (ex: stroke, aneurysm, hemorrhage, etc.) ______________________________________________________________

Please describe: _____________________________________________________________________________________

__________________________________________________________________________________________________

Head Trauma Case History Form

Related Articles

Related forms

Related Categories