PHYSIOTHERAPY I CHIROPRACTIC MASSAGE I LASER THERAPY I CUSTOM ORTHOTICS SHOCKWAVE THERAPY
MVA Questionnaire
Patient's Name
1. Y ou were:
Driver
Passenger (front seat)
Passenger (back seat)
2. Were you wearing a seatbelt?
Yes
No
3. Type of collision:
Rear-end
T -hit (side)
Head-on
Roll over
4. Head position at time of impact:
Straight ahead
Looking right
Looking left
5. Did you have immediate symptoms at the exact moment of impact?
Yes
No
6. Do you recall hitting your head inside the vehicle
Yes
No
7. Did you suffer any loss of consciousness at the time of collision?
Yes
No
8. Were you prepared for the impact?
Yes
No
9. If your symptoms were not immediate how soon after the accident did they begin?
Mins
Hours
Days
10. Did you see a Medical Doctor Immediate:
No
Yes (Emergency)
Yes (walk-in-clinic)
Yes (Family Doctor)
11. Have you seen any other health care practitioners as a result of your current injury?
Yes
No
Chiropractor
# of visits
Massage Therapist
of visits
12. Have any of these other health care practitioners completed and AB-2 Treatment Plan Form:
Yes
No
13. Have you seen any other specialists as a result of your injuries?
Orthopaedic Surgeon
Rheumatologist
Neurologist
Physiatrist
14. Are you currently employed
Yes
No
Are you currently working?
Yes
No
15. Have you had a previous motor vehicle accident?
Yes
No
16. If yes, did you receive Physical Therapy?
Yes
No
Patients Signature
Date
/
Month
/
Day
Year
Date
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