Personal Injury Questionnaire
File #: _____
Personal Information:
Health Insurance Information:
Today’s Date: ____________________________________
Name: _____________________________________________
I prefer to be called: _____________________________
Address: __________________________________________
___________________________________________________
Sex
 Male
 Female
If minor, name of parent or guardian
_______________________________________________________
Home Phone: _______________________________________
Work Phone: _______________________________________
Email: _______________________________________________
Social Security Number: __________________________
Date of Birth: _______________________________________
Height: ____________
Weight: ___________
Marital Status: ___________________________________
Number of Children: ____________________________
Do you have Health insurance?
 YES
 NO
Employer Information:
Occupation: ______________________________________
Employer: ________________________________________
Address: _________________________________________
Emergency Contact:
Who should we contact in case of Emergency?
___________________________________________________
Phone Number:
___________________________________________________
Relation:
___________________________________________________
Address:
_______________________________________________________
_______________________________________________________
_______________________________________________________
Attorney Information:
Attorney Name: __________________________________
Phone Number: __________________________________
Primary Care Physician Information:
Name____________________________________________
Phone Number_________________________________
Insurance Company:
Policy Holder’s Name______________________________
Policy Number_____________________________________
Address_____________________________________________
_______________________________________________________
Phone Number__________________________________
Auto Insurance Information:
Do you have Auto Insurance?  YES  NO
Insurance Company____________________________
Policy Number__________________________________
Address_____________________________________________
________________________________________________
Phone Number__________________________________
Adjuster’s Name________________________________
Claim Number __________________________________
Accident Information:
Date______________________________________________
Time _____________________________________________
Was it reported to the police?  YES  NO
Was a traffic Violation issued?  YES  NO
To Whom________________________________________
Location of the accident
_______________________________________________________
_______________________________________________________
Number of Passengers_________________________
Were there other witnesses?  YES  NO
Make/Model of vehicle ________________________
Please explain in detail how the accident
occurred:
_______________________________________________________
_______________________________________________________
In which direction were you heading?
N S E W
Approx. speed of the vehicle _____________(MPH)
FILE NUMBER:
Personal Injury Questionnaire
Accident Description Information:
Check the description that applies:
Actions of the patient’s vehicle:
 Crossing the
 Stopped at the
intersection
intersection
 Stopped for a
 Stopped for traffic
pedestrian
 Traveling at posted
 Traveling faster than
speed limit
speed limit
 Turning
How was your vehicle hit?
 Hit head on
 Hit on the right rear
 Hit on the left front
 Rear-ended
 Hit on the right
Other:__________________
front
 Hit on the left rear
Damage to your vehicle?
 Complete
 Minimal
 Extensive
 Moderate
 Snowed over
 Wet
AT THE MOMENT OF IMPACT…
Your body position:
 Leaning Forward
 Turned to the Left
 Slouched down in
 Turned to the Right
seat
 Straight
Direction body was thrown :
 Backward then
 Forward then
Forward
backward
 To the Left
 To the right
 About the vehicle
 Outside vehicle
 Under vehicle
Did any part of your body strike anything in
the vehicle?
 YES
Part of Body_________________________
Part of Vehicle_______________________
 NO
Describe the second vehicle:
 Compact
 Full-Size
 Mid-Size
 Semi Trailer
 Pick up Truck
Make: _____________ Model: ______________
Year: ______________ Est. Speed: _________(MPH)
Head position at impact:
 Straight
 Turned to the Left
 Tilted Forward
 Turned to the Right
Direction head was thrown;
 Backward then forward
 Forward then backward
 Side to Side
Damage to other vehicle:
 Complete
 Extensive
 Minimal
 Moderate
Weather conditions:
 Clear
 Cloudy
 Foggy
 Rainy
 Sunny
Road Conditions
 Damp
 Dry
 Dry with Ice  Iced over
patches
File #: _____
 Drizzling
 Stormy
Were you _______________by the impact?
 Aware
 Surprised
Were your brakes?
 Applied
 Partially Applied
FILE NUMBER:
Personal Injury Questionnaire
Type of restraint:
 Lap Belt
 Shoulder Belt
 Shoulder Lap Belt
Place patient was seated in the vehicle
Back passenger right
 Driver
side
Back passenger
 Front Passenger
middle
Other: __________________
 Back Passenger
driver side
Did airbags deploy?
 YES
 NO
Did the accident render you unconscious?
 YES, For _______________________(length of time)
 NO
Post Injury Information:
Were you seen at a medical Facility following
your accident?
 Yes
 No
IF YES please provide the following:
Name of the facility:
____________________________________
Name of Doctor
__________________________________________________
Type of Doctor:
D.C. M.D.  D.O. D.D.S
File #: _____
a) Yes
b) No
Was a CAT SCAN Taken?
a) Yes
b) No
Was medication prescribed
a) Yes (Please list below)
b) No
_______________________________________________________
_______________________________________________
How did you get there
a) Ambulance
b) Private transportation
When did you go?
a) Immediately
b) Next day
c) 2 days plus
Have you seen any other doctor(s) since the
accident? If so please list
_______________________________________________________
_______________________________________________________
Have you missed any work since the
accident?
YES,__________________________(Amount
NO
Type of Treatment received:
_______________________________________________________
_______________________________________________________
___________________________________________
Were X-Rays Taken?
a) Yes
b) No
Was an MRI Taken?
FILE NUMBER:
Personal Injury Questionnaire
SYMPTOMS
Do you have lacerations, cuts or bruising?
 Head/Face
 Neck
 Seatbelt
Bruising
 Cuts or
 Cuts or
 Cuts or
bruising on
bruising on
bruising on
chest
arms
legs
Other: ________________________________
Indicate the symptoms that are a result of
this accident:
Dizziness
 Memory Loss
 Headaches
Blurred Vision
 Buzzing in Ear
Difficulty sleeping
Arm/Shoulder Pain
Numb hands/
Fingers
 Tension
 Neck Pain
 Neck Stiff
 Jaw Problems
 Irritability
 Fatigue
 Chest Pain
 Short Breath
Stomach upset
Nausea
Back Pain
 Low Back pain
Back Stiffness
Leg Pain
Numb Feet/Toes
Other
HEAD INJURIES:
 Were you knocked
out or unconscious
 Face Pain
 Dizziness
 Balance Problems
 Disoriented/
Confusion
 Attention Problems
 Change in sense of
smell or taste
 Impatience
 Memory Problems
 Appetite Change
 Visual
Disturbances
 Headaches
 Pupils different sizes
 Difficulty Walking
 Room Spins
 Day Dreaming
Hearing Problems
 Sleepiness
 Difficulty Speaking
 Very Tired
 Sleep Difficulties
 Flashbacks to incident
 Problems reading
or writing
 Problems learning
new things
 Problems
remembering
numbers
 Difficulty
remembering things
 Change in Sexual
Functioning
 Change in
Personality
 Mood Swings
 Agitation
 Helplessness
 Apathy
 Frustration
 Problems adding or
subtracting
 Problems
understanding
 Difficulty
Concentrating
 Difficulty making
decisions
 Nausea/Vomiting
 Wanting to be alone
 Sadness
 Anger
 Reduce Confidence
 Irritability
Other:___________________
JAW PROBLEMS:
 Jaw Pain
 Clicking
 Pain while
Talking
File #: _____
 Pain while
yawning
 Pain while
chewing
 Pain moving
jaw from side
to side
NECK INJURIES:
 Neck Pain
 Neck Pain, numbness, tingling, weakness that
radiates or goes down to RIGHT shoulder, arm,
forearm or hand
 Neck Pain, numbness, tingling, weakness that
radiates or goes down to LEFT shoulder, arm,
forearm or hand
 Neck pain, numbness, tingling, weakness that
radiates or goes down to RIGHT UPPER BACK
 Neck pain, numbness, tingling, weakness that
radiates or goes down to LEFT UPPER BACK
 Neck pain that causes headaches
 Neck spasms or shoulder spasms
 Popping, clicking or clicking sound with neck
movement.
FILE NUMBER:
Personal Injury Questionnaire
SHOULDER INJURIES:
Shoulder pain :
L R BOTH
Shoulder pain with movement L R BOTH
Shoulder Spasms:
L R BOTH
Sharp Shoulder pain
Dull Shoulder pain
Achy Shoulder pain
Pins and needles shoulder pain
Shoulder pain that radiates/shoots pain into
arm
Other: _______________________________________
UPPER ARM PAIN:
R
L
 Dull
 Ache
 Sharp
 Stabbing
Other: ________________
BOTH
ELBOW PAIN:
R
L
BOTH
Dull
Ache
Sharp
Stabbing
Other:___________________
FOREARM:
R
L
BOTH
Dull
Ache
Sharp
Stabbing
Other:__________________
WRIST PAIN:
R
L
Dull
Ache
Sharp
Stabbing
Other: __________________
BOTH
HAND PAIN:
R
L
BOTH
Dull
Ache
Sharp
 Stabbing
Other: ________________
File #: _____
MIDBACK PAIN OR UPPER BACK PAIN:
 Upper or midback pain
 Upper back pain, numbness, tingling,
weakness that radiates or goes down to RIGHT
shoulder, arm, forearm or hand
Upper back pain, numbness, tingling,
weakness that radiates or goes down to LEFT
shoulder, arm, forearm or hand
Upper or mid back spasms
LOW BACK PAIN
Low Back Pain
Low Back Pain, numbness, tingling, weakness
that radiates o goes down to RIGHT buttock,
thigh leg or foot
Low back pain, numbness, tingling, weakness
that radiates or goes down to LEFT buttock,
thigh leg or foot
Low back spasms
PELVIC OR SACRAL PAIN
 Pelvic pain, numbness, tingling, weakness
that radiates or goes down to RIGHT buttock,
thigh leg or foot
 Pelvic pain, numbness, tingling, weakness
that radiates or goes down to LEFT buttock,
thigh, leg or foot
 Sacral pain (tail bone)
 Coccygeal or coccyx (tail bone) pain
HIP PAIN
R
L
BOTH
 Left Hip Pain
 Left Hip Pain that radiates or goes down to
LEFT buttock, thigh, leg or foot
 Right Hip Pain
 Right hip pain, numbness, tingling, weakness
that radiates or goes down to RIGHT buttock,
thigh, leg or foot
UPPER LEG PAIN:
R
L
BOTH
 Upper leg pain that radiates to knee
 Upper leg spasms
KNEE PAIN:
FILE NUMBER:
R
L
BOTH
Personal Injury Questionnaire
 Knee Pain that radiates to calf
 Knee pain that radiates to calf and ankle
 Knee pain that radiates to calf, ankle and foot
ANKLE PAIN:
R
L
 Ankle pain that radiates to foot
 Ankle and foot pain
BOTH
 FOOT PAIN:
R
L
BOTH
 CHEST PAIN
 STOMACH PAIN
 OTHER SYMPTOMS:
_______________________________________________________
Did you ever experience similar symptoms
prior to the accident?
 Yes  No
File #: _____
How many hours are in your normal workday?
______________________________
Please indicate your daily job duties and any
activities that you are occasionally asked to
perform:
 Standing
 Typing
 Work w/arms above
head
 Driving
 Bending
 Crawling
 Twisting
 Operating
Equipment
 Lifting
 Walking
 Sitting
 Stooping
What positions can you work in with minimum
physical effort, and for how long?
_________________________________________
Do you work with others who can help you
with any heavy lifting?
_________________________________________
Has your condition
Improved
Worsened
Stayed the Same
While in recovery, are there any light duty
tasks you could request?
 YES  NO
Is the condition affecting your
Work
Sleep
Daily Routine
Please indicate your degree of difficulty (on a
scale of 1-10, 1 being uncomfortable, 5 being
uncomfortable, and 10 being painful) in
performing the following activities:
____Lying on your back
____Running
____Lying on Side
____Sports
____Lying on Stomach
____Working
____Sitting
____Lifting
____Standing
____Bending
____Stretching
____Kneeling
____Sexual Activity
____Pulling
____Walking
____Reaching
Questionnaire Continued on following page…
FILE NUMBER:
Personal Injury Questionnaire
Health History:
Have you ever had any of the following
diseases or conditions?
 Heart
 Congenital
Attack/Stroke
Heart Defect
 Alcohol/Drug
 HIV/AIDS
Abuse
 Freq. Neck Pain
 High/Low Blood
Pressure
 Severe/Freq
 Fainting/
Headaches
Seizure/Epilepsy
 Freq. Neck Pain
 Arthritis
 Diabetes
 Lower Back
Problems
 Heart Surgery or
 Mitral valve collapse
pacemaker
 Venereal disease
 Shingles
 Emphysema
 Psychiatric problems
 Kidney problems  Sinus problems
 Difficulty
 Artificial
breathing
bones/joints
 Heart murmur
 Artificial valves
 Hepatitis
 Cancer
 Anemia
 Rheumatic fever
 Ulcer/colonitis
 Asthma
 Tuberculosis
Please list any other medical conditions that
you have of have ever had:
_______________________________________________________
_______________________________________________________
Please list any allergies:
_______________________________________________________
_______________________________________________
Please list previous surgeries and dates:
_______________________________________________________
_______________________________________________________
Please list any past motor vehicle accidents
or traumas:
_______________________________________________________
_______________________________________________________
File #: _____
Is there anything else about your health
history or family health history that you feel
is important to share?
_______________________________________________________
_______________________________________________________
_______________________________________________________
Do you exercise?
 YES  NO
Are you on a special diet?
 YES  NO
Since: ______/_________/__________
Do you smoke?
 YES  NO
How much? ______________________
How long? _______________________
Are you wearing?
 Orthotics  Heel Lifts  Arch Supports
For Women:
Are you taking Birth Control?
 YES  NO
Are you Pregnant?
 YES  NO
Patient/Legal Guardian Signature:
___________________________________________________
Date:
_____________________________________________
FILE NUMBER: