TRAUMA QUESTIONNAIRE
PLEASE ANSWER ALL QUESTIONS
I.
DO NOT WRITE IN THIS SPACE
Name:_____________________________ Date:______________
Date of trauma: ________________________________________
Was your trauma from:
Auto accident? ___________________ Fight? _______________
Other? _______________________________________________
How did the trauma happen? _____________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
II.
Make of your car?_____________ Other vehicle______________
Speed of your car? ____________ Other vehicle______________
Were you the driver? ____________________________________
Passenger? Front seat? _______________ Back seat? __________
Other? ________________________________________________
Were you wearing a seat belt? _____________________________
Shoulder strap? _________________________________________
Did you have a head rest? _______________ Air bag? _________
What did you strike? Windshield?__________________________
Steering wheel? ______________Dashboard? ________________
Other? ________________________________________________
III.
During the trauma did you strike your:
Skull? ________________ Face around nose? ________________
Lower jaw? __________ Neck? __________ Chest? ___________
Did you have whiplash? __________________________________
Did you have cuts? _____________ Abrasions? _______________
Bruises? ______________________________________________
Bleeding from mouth? ___________________________________
Bleeding from nose? ____________________________________
Bleeding from ears? _____________________________________
IV.
Were you knocked out:
Seconds? __________________ Minutes? ___________________
Hours? ____________________ Days? ______________________
What is your first memory after the trauma? __________________
______________________________________________________
TH
6540 4 Street North, Suite A
St. Petersburg, FL 33713
p. 727-525-0155
f. 727-520-7173
TRAUMA QUESTIONNAIRE PAGE 2
PATIENT NAME:
V.
DO NOT WRITE IN THIS SPACE
Immediately after the trauma, were you seen and treated at an:
Emergency room? ______________________________________
Name
Doctor’s office? ________________________________________
Name
Other? ________________________________________________
Name
When were you first seen for evaluation after the trauma?_______
______________________________________________________
VI.
Did you have x-rays of your skull? _________________________
Face? ___________ Neck? ______________ Other? ___________
Did you have a CT scan? ________________________________
Other tests? ____________________________________________
VII.
Where did you first hurt? _________________________________
When did you first notice? ________________________________
Headache? ________________ Neck pain? __________________
Jaw pain? _________________ Ear pain? ___________________
Jaw joint noises? _______________________________________
Before the trauma, had you ever noticed:
Headache? ________________ Neck pain? __________________
Jaw pain? _________________ Ear pain? ___________________
Jaw joint noises? _______________________________________
Pain with chewing? _____________________________________
Jaw locking? __________________________________________
VIII.
Before this trauma, had you ever received any other injury:
Face? ____________________ Head? ______________________
Neck? ________________________________________________
What type? ____________________________________________
Other car accidents? ________________ When? ______________
IX.
List all doctors who have treated you for this trauma and explain
what they have done:
Emergency physician: ___________________________________
______________________________________________________
Family doctor: _________________________________________
______________________________________________________
Dentist: _______________________________________________
______________________________________________________
TH
6540 4 Street North, Suite A
St. Petersburg, FL 33713
p. 727-525-0155
f. 727-520-7173
TRAUMA QUESTIONNAIRE PAGE 3
PATIENT NAME:
DO NOT WRITE IN THIS SPACE
Oral surgeon: __________________________________________
_____________________________________________________
Orthopedic surgeon: ____________________________________
_____________________________________________________
Neurologist: ___________________________________________
_____________________________________________________
Neurosurgeon: _________________________________________
_____________________________________________________
Chiropractor: __________________________________________
_____________________________________________________
Psychologist/psychiatrist: ________________________________
_____________________________________________________
Physical therapist: ______________________________________
_____________________________________________________
Other: _______________________________________________
_____________________________________________________
Other: _______________________________________________
_____________________________________________________
X.
I have completed the above to the best of my knowledge and I
personally have filled out each blank in my own handwriting.
_____________________________________________________
Signature
_____________________________________________________
Date
TH
6540 4 Street North, Suite A
St. Petersburg, FL 33713
p. 727-525-0155
f. 727-520-7173