Posture Performance & Wellness
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About us
Patient Resources
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Personal Injury
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Name
*
First
Last
Date of Accident
Where did accident happen? Describe the accident in your words:
What was your position in the car?
Driver
Passenger
If Driver, were your hands on the steering wheel?
Left
Right
Both
If Passenger, were you sitting in
Front
Right Rear
Left Rear
Did your vehicle strike another vehicle?
Yes
No
Was your vehicle struck by another vehicle?
Yes
No
Angles of impact… First Collision:
Front
Back
Left
Right
If Second Collision:
Front
Back
Left
Right
Were you wearing a seat belt?
Yes
No
Did you brace for impact?
Yes
No
If Yes, then
I braced with my hands
I braced with my feet
Which way were you facing at the time of impact?
Straight Ahead
Left
Right
Did you strike anything in vehicle at time of impact?
No
Yes | If yes, specify what part of your body struck what: ie head chest chin shoulder Right / Left Knee
Steering Wheel
Head
Chest
Chin
Shoulder
Right / Left Knee
Dashboard
Head
Chest
Chin
Shoulder
Right / Left Knee
Other
Windshield
Head
Chest
Chin
Shoulder
Right / Left Knee
Other
Roof
Head
Chest
Chin
Shoulder
Right / Left Knee
Other
Left Side Door
Head
Chest
Chin
Shoulder
Right / Left Knee
Other
Right Side Door
Head
Chest
Chin
Shoulder
Right / Left Knee
Other
Left Side Window
Head
Chest
Chin
Shoulder
Right / Left Knee
Other
Right Side Window
Head
Chest
Chin
Shoulder
Right / Left Knee
Other
Other
Head
Chest
Chin
Shoulder
Right / Left Knee
Other
Did the seat back bend / break?
Yes
No
Immediately following the accident, how did you feel?
Dizzy/Dazed
Disoriented
Unconscious
Nervous
Nauseous
Upset
Weak
Other
Did you go to hospital?
Yes
No
Were you admitted to the hospital?
Yes
No
if yes how long?
If you went to hospital, when?
At time of Accident
Next Day
How did you get to hospital?
Ambulance
Police Car
Private Transportation
Name of Hospital:
Attended by Dr. (Name)?
What treatment was given
None
Placed in a Cervical Collar
X-rayed
Given Stitches
Bandaged
Given Pain Medication
Given Instructions regarding Concussions
Given Instructions regarding Sprains and Strains
Physical Therapy
Instructed to call a Orthopedic Surgeon
Instructed to call a Private Physician
Referred to this Office for Treatment
Other
Have you seen any other doctor as a result of this accident?
Yes
No
Doctor's Name
Neck Pain | Check off the areas that the pain runs into from the neck
Left shoulder
Right shoulder
Left arm
Right arm
Left forearm
Right forearm
Left hand
Right hand
None
Others
Headache
Migraine Headache
Upper Back Pain
Ringing in Ears
Left
Right
None
Blurry Vision
Left
Right
None
Wrist Pain
Left
Right
None
Jaw Pain
Left
Right
None
Other Disturbances
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 | Select the areas of radiation, if any…..
None
Buttocks
Left buttock
Left Thigh
Left Knee
Left Foot
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
Right Hand
Left Upper Arm
Right Upper Arm
Left Foot
Right Foot
Left Leg
Right Leg
Additonal Symptoms/ Complaints
Have You lost any time from work due to your injuries?
Yes
No
If yes please give dates:
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.)
Submit
