Motor Vehicle Accident Questionnaire Form Page 2
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1
2CHIEF COMPLAINTS/SYMPTOMS
NECK PAIN
none
left shoulder
left arm
left forearm
left hand
Check off the areas that the
pain runs into from the neck:
right shoulder
right arm
right forearm
right hand
headache
Migraine Headache
upper back pain
Ringing
Yes
No
Left
Right
Both Ears
in Ears
Blurry
Yes
No
Left
Right
Both Eyes
Vision
Wrist
Yes
No
Left
Right
Both Wrist
Pain
Jaw
Yes
No
Left
Right
Both Sides
Pain
Dizziness
nervousness
fatigue
anxiety
depression
excessive irritability
fear of driving in a car
a loss of concentration
jaw clenching
grinding of teeth at night
nightmares
difficulty with sleeping at night
LOW BACK PAIN
none
buttocks
left buttocks
left thigh
left knee
left foot
Select the areas of radiation, if any…
right buttock
right thigh
right knee
right foot
Hip pain
Left
Right
Bilateral
Knee Pain
Left
Right
Bilateral
Foot Pain
Left
Right
Bilateral
NUMBNESS
Left Hand
Left Upper Arm
Right Hand
Right Upper Arm
Left foot
Left Leg
Right Foot
Right Leg
Additional Symptoms/Complaints:
Have you lost any time from work due to your injuries?
Yes
No
If yes please give time frame (eg: 1 week):
_________________________________
Type of employment:
__________________________________________________
Have you had previous injuries or accidents?
Yes
No
Description of previous accident:
_________________________________________
Description of previous injuries:
__________________________________________
Is there any residual pain from the previous injury?
Yes
No
How much better did you feel prior to your current condition? (Example 100%, 80% etc.)
_________
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