Take this 3 minute Accident Quiz
I have been involved in :

an automobile accident
work related accident

slip and fall accident

My accident occurred with the last:

1-3 months

4-8 months

9 months

1 year

 

As a result of the accident, I experience the following symptoms:

headache dizziness irritability
stiff neck loss of balance depression
neck pain heavy feeling of head insomnia
back pain sensitivity to light (eyes) fatigue
shoulder pain concentration loss nervousness
arm pain pain behind eyes tingling sensation
wrist pain ringing in ears cold hands/feet
hand pain digestive troubles    
Radiation of pain:
right arm left arm
right leg left leg

Aggravation upon:
walking sitting
standing bending

     

Did you go to the hospital? yes no By ambulance? yes no

Did you receive treatment? yes   no If so, what did you receive?

The accident has affected my activities as follow:
Due to pain, I am restricted in:
lifting light weights sleep less than 6 hours
lifting medium weights sleep less than 4 hours
lifting heavy weights sexual activity
sitting more than 10 min. grip strength
sitting more than 30 min. walks of 1 mile
standing more than 10 min walks of less than ½ mile
standing more than 30 min. travel of 2 hours or more
    travel of 1 hour or more

Pain intensity is:
minimal slight
moderate severe




Pain frequency is:
  25% of day   50% of day
  75% of day   100% of day



 

I take medication for:
pain   sleep



If more than 3 boxes have been checked, click below for :
Information about my health status including consultation with Dr. at no cost!
Information about my legal rights and referral to three trial attorneys

Your Name:
Phone Number:
E-mail:
Questions or
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