Whiplash Injury Medical History

Please complete the following in English if possible:

Personal Information:

Patient's Full Name:	* required field
Full Address:
Country:	* required field
Telephone:	* required field
Fax:
Email:	* required field
Date of Birth:	Gender:  Male  Female
What Langauges do you speak?

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History of Whiplash Injury:

Date of Injury:	(mm/dd/yyyy)    Height:  cm    inch
	Weigth: Kg    lbs
Description of Accident:
Have you had a CT Scan?	Yes  No     Results:
Have you had a MRI?	Yes  No     Results:
Are you working at this time?	Yes  No
What is your profession?
Are you receiving disability at this time?	Yes  No

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Symptoms: (Check Where Pain Occur)

Front Head Pain Area Eye 1. Right 2. Left or Both Head 3. Right 4. Left or Both Back Head And Neck Pain Area Head 5. Right 6. Left or Both Head Base 7. Right 8. Left or Both Neck 9. Right 10. Left or Both Left Side Pain 11. Head 12. Eye 13. Jaw 14. Base Head 15. Neck Right Side Pain 16. Head 17. Eye 18. Jaw 19. Base Head 20. Neck

Face Pain          Right  Left    Both   Shoulder Pain     Right  Left    Both   Arm Pain           Right  Left    Both   Leg Pain            Right  Left    Both		Neck Pain          Right  Left    Both    Back Pain          Right  Left    Both

Please describe your pain in words:
Change in sleeping patterns:  Yes   No	How many hours do you sleep?
Dizziness:  Yes   No	When:    Walking -         Yes   No               Laying Down -  Yes   No

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Treatment Sought:

Orthopedic Medical Doctor  Neurologist  Rehabilitation Doctor  Chiropractor  Physical Therapy  Other

Acupuncture  Reiki  Surgery Please describe your surgical procedure & date surgery was preformed:

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All Current Medications:

List Name	Dose	Frequency

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Comments:
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  · USA Tel: 402-559-3090 · Fax: 402-552-2410 · E-mail: whiplash@nebraskamed.com
  · Contact: Nizar Mamdani, Executive Director
  · Tel: 402-559-3656 · E-Mail: nmamdani@nebraskamed.com
  · Websites: www.whiplashinjury.net  - www.unmc.edu  - www.nebraskamed.com