Orange Car Accident Treatment | Truth About Whiplash
DR. BARRY L. MARKS, DC

 Auto Accident Needs Analysis Questionnaire

Congratulations! You May Now Complete
the Questionnaire

This questionnaire was designed by our medical and legal experts to determine what your needs are and the best possible solutions.

Follow the directions and answer each question. Upon completion, select "submit" and your answers will be
transmitted for analysis.

You will receive an analysis and personalized report
from our car accident experts only if you provide contact info.

If you would like an appointment for a consult with Dr Marks, be sure to check the box below and fill in best time of day in the field below and we will get you in ASAP.

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
I want an appointment ASAP! 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
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29     30
31     32
33 34 35
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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...

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

You are finished! Click "submit" below to transmit your answers

Thank You For Completing the Questionnaire. You Will Receive a Personalized Report with Your Analysis from Our Auto Accident Experts in 24-48 Hours

Orange County Car Accident Treatment | Truth About Whiplash
DR. BARRY L. MARKS, DC
 

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