Date of Birth

Sex

Sex at birth

Are you, or may you be, pregnant?

Yes

Did you have any of your pain before the accident? Yes No

If so, where was your pain?

Patient Condition Questionnaires

Please select the area(s) where you are currently experiencing symptoms:

IF YOU ARE TAKING ANY MEDICATION FOR PAIN, ANSWER THESE QUESTIONS AS IF YOU WERE NOT TAKING MEDICINE

Neck Pain Low Back Pain Shoulder, Arm or Hand Hip, Leg or Knee

Disabilities of Arm, Shoulder and Hand (DASH)

Please select the ONE choice in each section that most applies to you.

Activity

No Diff

Mild

Mod

Severe

Unable

Social & Work Impact

Symptoms (Past Week)

Symptom

No Diff

Mild

Mod

Severe

Unable

24. Arm, shoulder or hand pain

25. Pain when performing specific activity

26. Tingling (pins and needles)

27. Weakness in arm/shoulder/hand

28. Stiffness in arm/shoulder/hand

Sleep & Confidence

Statement (Confidence)

No Diff

Mild

Mod

Severe

Unable

30. I feel less capable/useful due to problem

Lower Extremity Functional Scale (LEFS)

Please select the ONE choice in each section that most applies to you.

Activity

Unable

Quite Bit

Mod

Little

No Diff

History

What was the date of your accident?

Were you (in/on) a:

Car

Scooter

Bicycle

Pedestrian

Motorcycle

Rideshare

Other (Describe):

Please briefly describe how the accident happened:

Do you have any pain, numbness or tingling traveling from your neck or back? Yes No

If yes, describe what you feel.

Were you:
Passenger | Driver | N/A

Seatbelt worn?
Yes No

Airbags go off?
Yes No

Did you go to the hospital, urgent care, see any other medical provider or have any other treatment after the accident Yes No

If yes, what hospital or urgent care? Were any scans taken? Yes No

If yes, were there any findings?

Was there any bruising to your body due to the accident? Yes No

If so, where?

Are you taking any pain medication due to the accident? Yes No

If so, what is the medication?

Did you miss any work due to the accident? Yes No

If yes: What is your job?

How much time have you missed?

History of spinal surgeries? Yes No

If yes, list year and type:

History of cancer? Yes No

If yes, kind, diagnosis date, and remission status:

Medical History

Patient Consent

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Patient Demographics

Patient Condition Questionnaires

Neck Pain Disability Index

Section 1: Pain Intensity

Section 2: Personal Care

Section 3: Lifting

Section 4: Reading

Section 5: Headache

Section 6: Concentration

Section 7: Work

Section 8: Driving

Section 9: Sleeping

Section 10: Recreation

Low Back Pain Disability Index

Section 1: Pain Intensity

Section 2: Personal Care

Section 3: Lifting

Section 4: Walking

Section 5: Sitting

Section 6: Standing

Section 7: Sleeping

Section 8: Sex Life

Section 9: Social Life

Section 10: Travelling

Disabilities of Arm, Shoulder and Hand (DASH)

Social & Work Impact

Symptoms (Past Week)

Sleep & Confidence

Lower Extremity Functional Scale (LEFS)

History

Medical History

Patient Consent

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