Car Accident Questionaire

Your Contact Info to Receive Results

Full Name
Street Address
City, State Zip
Email
Telephone

My Reasons For Completing the Questionnaire
(Check all that apply. Everyone Gets a Reply No Matter What Box is Checked)

Just curious	Gathering info
Had accident, want help, but I'm out of your area (We refer!)	Had an accident on:
I need legal advice	I need treatment
Other:	Other:

About My Accident
(Check all that apply)

Other party at fault	My fault
I was struck by Car P/U Truck SUV Bus Semi Taxi Other	I struck Car P/U Truck SUV Bus Semi Pole Wall
I need legal advice	I need treatment
Other:	Other:

Case Status
(Check All that apply)

	Time Frame
	Accident is recent and I need advice or help
	Accident was months ago or longer and I need advice or help
	Accident was more than 2 years ago and I filed to preserve my statute of limitations
	Accident was more than 2 years ago and I did not file to preserve my statute of limitations

	Legal Status
	I have not attempted to settle my case yet
	I have attempted to settle my case, but need help
	The auto insurance company refuses to settle with me
	The auto insurance company has totally rejected my claim
	I have a police report
	I do not have a police report
	Other:

	Medical Status
	I have completed medical treatment with a car accident medical specialist
	I have completed treatment with a non-specialist chiropractor, medical doctor, therapist
	Treatment is current with a car accident medical specialist
	Treatment is current with a non-specialist chiropractor, medical doctor, therapist
	Other:

My Vehicle Status
(Check All that apply)

	My Vehicle Damage
	My vehicle suffered $0-500 in damage
	My vehicle suffered $501-1,000 in damage
	My vehicle suffered $1,001-1,500 in damage
	My vehicle suffered more than $1,500 in damage
	My vehicle was "totaled"
	Damage to the: Front Rear Left side Right side
	I have repair receipts I have photos of vehicle(s)

My Concerns
(Please briefly list, in order of importance, your top 3 concerns regarding your car accident)

1
2
3

Pain Locator
(Use the numbered diagram to locate your pain. Check all that apply)

My pain is located...

I do not have any pain

	1
2		3
4	5	6
7		8
9		10
11		12
13	14	15
16	17	18
19		20
21		22
23		24
25		26
27		28
29		30
31		32
33	34	35
	36
37		38
39		40
41		42
43		44
45		46
47		48
49		50

Comments:

Pain Descriptor
(Use numbered diagram to describe the quality of your pain. Use commas between numbers)

Example: Ache at location(s): [4,5,6]
Burning at location(s): [10,12,14]

My Pain feels like...

Dull/aching	@ location:
Burning	@ location:
Electric	@ location:
Pins & Needles	@ location:
Sharp/Stabbing	@ location:
Other	@ location:
Other	@ location:

Frequency Rater
(Select the best answer for how often you feel your pain)

My Pain Occurs...

2 hrs or less

up to 4 hrs a day

up to 6 hrs a day

up to 8 hrs a day

all waking hours

Severity Rater
(Indicate how bad or severe your pain is below)

My Pain is...

	Minimal and is easily forgotten
	Mild and I feel it during activity but it does not interfere with any activities
	Slight and interferes only with strenuous activities
	Slight to moderate and interferes with light activities and prevents strenuous activities
	Moderate and prevents light activities
	Severe and prevents all activities

Pain Aggravators
(Check all the conditions below that aggravate or make your pain worse)

My pain is aggravated by...

	Sitting
	Standing
	Walking
	Lying Down
	Bending Forward
	Bending Backward
	Coughing and/or Sneezing
	Lovemaking
	Driving
	Other:

Failed Treatments
(Despite trying the following treatments, I continue to suffer with back and/or leg pain)

Acupuncture	Chiropractic
Home Exercises	Physical therapy
Over the Counter Medications	Prescription Medications
Nerve blocks	Epidural steroid injection
Minimally Invasive Disc Surgery	Disc Herniation Surgery
Laminectomy Surgery	Fusion Surgery

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