Name: _____________________________________________________________ Record # : __________

Address: ___________________________________________________________ Telephone: __________

WHIPLASH-ASSOCIATED DISORDERS (WAD)

Minimum data/Initial visit (FORM A)

Completed by patient or with assistance

Check the appropriate box or write answers where applicable

A. GENERAL INFORMATION

1. Today's date: Day __ Month __ Year __

2. Date of birth: Day __ Month __ Year__

3. Gender: M F

4. Height: ____________ cms

feet/inches

5. Weight:____________ kg

lbs

6. Marital status:

Married, cohabiting

Formerly married

Never married

7. Number of dependents: _______

(children and others)

8. Education level:

Grade 8 or less

Partial high school

High school graduate

Post-secondary, CEGEP or

some university

University graduate

9. Combined annual family income:

$0 - $20,000

$20,001 - $40,000

$40,001 - $60,000

above $60,000

10. Employment status:

Paid full-time

Paid part-time

Homemaker

Student

Unemployed

Retired

Other

11. Main work activity:

Heavy labour

Light labour

Mostly sitting at a desk

Mostly standing

Mostly walking or moving about

Driving or operating a vehicle

B. COLLISION INFORMATION

12. Collision date: Day__ Month__ Year__

13. Did the collision occur in the course of

your work ?

Yes

No

14. Were you?

Occupant of car or van

Occupant of a bus

On a bicycle

On a motorcycle

Pedestrian

Do not know

If occupant of car, van or bus, answer following questions; otherwise skip to question 21

15. From which direction was the main

impact to your vehicle?

Front

Rear

Driver's side

Passenger's side

Do not know

16. Did your vehicle roll over?

No

Yes

Do not know

Name: _____________________________________________________________ Record #: __________

17. Was the vehicle drivable after the

accident?

No

Yes

Do not know

18. Circle the place where you were seated

during the collision.

Front left Front Front right

(driver) Center (passenger)

Middle Middle Middle

Left Center Right

Rear Rear Rear

Left Middle Right

19. Was your seat belt fastened?

No

Yes, lap only

Yes, shoulder only

Yes, lap and shoulder only

Not applicable

Do not know

20. Was there a headrest on your seat?

No

Yes, fixed

Yes, adjustable

Yes, type unknown

Not applicable

Do not know

C. GENERAL HEALTH BEFORE

COLLISION

21. How was your health before this

collision

Excellent

Very good

Fair

Poor

22. How often did you have any of the

following before this collision?

Never Some- Always

or times Often or

almost almost

never always

Headache

Ache/pain in

lower back

Ache/pain in

neck/shoulder

Ache/pain in

jaw

23. Have you been injured in a motor

vehicle collision in the past?

No

Yes

Do not know

If yes, which part(s) of the body was injured

Head/face

Neck/shoulder(s)

Back

Arm(s)

Leg(s)

Other

Do not know

D. POST-COLLISION SYMPTOMS

24. Did you lose consciousness?

No

Yes

Do not know

25. Did you hit your head?

No

Yes

Do not know

26. Did you break any bones?

No

Yes

Do not know

Name: ______________________________________________________________ Record #: __________

27. Have you felt the following symptoms since this collision? Please check the appropriate box(es).

Present Beginning of symptoms If you have the symptom now, how severe is it?
Symptoms No Yes Day of collision Day

after to fourth

day

Later

than

fourth

day

Do not

know

Mild Moderate Severe Unbearable
Neck/shoulder pain
Reduced/painful neck movements
Headache
Reduced/painful jaw movement
Numbness, tingling, or pain in arm or hand Right
Left
Numbness, tingling, or pain in leg or foot Right
Left
Dizziness/ unsteadiness
Nausea/vomiting
Difficulty swallowing
Ringing in the ears
Memory problems
Problems concentrating
Vision problems
Lower back pain

Name: _____________________________________________________________ Record #: __________

E. PAIN DRAWING

(Carefully shade or mark in the areas where you feel any pain on the drawing below.)

F. FORM COMPLETED BY:

Yourself

Clinician

Other, specify ________________________________________

Name: _____________________________________________________________ Record #: ___________

WHIPLASH-ASSOCIATED DISORDERS (WAD)

Minimum data/Initial visit (FORM B)

To be completed by the Clinician

A. SPINE EXAMINATION

1. Date of examination: Day__ Month__ Year__

2. Pain/limitation in cervical spine

No Pain Limitation

Flexion

Extension

Right rotation

Left rotation

Right lateral flexion

Left lateral flexion

3. Palpatory tenderness

No

Yes

If yes: Left Midline Right

Cervical spine

Thoracic spine

Other, specify _______________________

____________________________________

B. NEUROLOGICAL EXAM

4. Normal or ... Sensory deficit Motor weakness Decreased deep tendon reflexes

Right Left Right Left Right Left

C5

C6

C7

C8

Other, specify ____________ _______________ _______________

C. DIAGNOSTIC TESTS

5. Plain X rays (cervical spine)

Normal

Degenerative changes

specify levels _____________________

Fracture/dislocation/subluxation

specify levels _____________________

Not indicated

6. Other specialized tests, specify:

____________________________________

____________________________________

D. DIAGNOSIS

7. Whiplash-associated disorder (WAD)

Grade I II III IV

8. Other injuries, specify: ________________

____________________________________

9. Other important medical conditions,

specify: _____________________________

____________________________________

E. MANAGEMENT PLAN

10. Reassurance

Yes

Not applicable

11. Activation

Return to usual activities ASAP

Delayed return to usual activities,

specify days: ________

12. Other treatments

Medications, specify: ______________

________________________________

Exercise, specify: _________________

________________________________

Mobilization/manipulation, specify:

________________________________

Other, specify: ___________________

_______________________________

13. Referral to specialized advice, specify:

__________________________________

__________________________________

F. REMARKS: ________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

G. CLINICIAN IDENTIFICATION: _______________________

Name: _____________________________________________________________ Record # : __________

Address: ___________________________________________________________ Telephone: __________

WHIPLASH-ASSOCIATED DISORDERS (WAD)

Minimum data/Follow up visit (FORM C)

Completed by patient or with assistance

Check the appropriate box or write answers where applicable

1. Date of visit: Day___ Month___ Year___

A. POST-COLLISION INFORMATION

2. Have you felt the following symptoms since your last visit ? Please check the appropriate box(es).

Present If you have the symptom

now, how severe is it?

Symptoms No Yes Mild Moderate Severe Unbarable
Neck/shoulder pain
Reduced/painful neck movements
Headache
Reduced/painful jaw movement
Numbness, tingling, or pain in arm or hand Right
Left
Numbness, tingling, or pain in leg or foot Right
Left
Dizziness/ unsteadiness
Nausea/vomiting
Difficulty swallowing
Ringing in the ears
Memory problems
Problems concentrating
Vision problems
Lower back pain

Name: _____________________________________________________________ Record #: __________

B. PAIN DRAWING

(Carefully shade or mark in the areas where you feel any pain on the drawing below.)

C. FORM COMPLETED BY:

Yourself

Clinician

Other, specify ________________________________________

Name: _____________________________________________________________ Record #: ___________

WHIPLASH-ASSOCIATED DISORDERS (WAD)

Minimum data/Follow up visit (FORM D)

To be completed by the Clinician

A. SPINE EXAMINATION

1. Date of examination: Day__ Month__ Year__

2. Pain/limitation in cervical spine

No Pain Limitation

Flexion

Extension

Right rotation

Left rotation

Right lateral flexion

Left lateral flexion

3. Palpatory tenderness

No

Yes

If yes: Left Midline Right

Cervical spine

Thoracic spine

Other, specify _______________________

____________________________________

B. NEUROLOGICAL EXAM

4. Normal or ... Sensory deficit Motor weakness Decreased deep tendon reflexes

Right Left Right Left Right Left

C5

C6

C7

C8

Other, specify ____________ _______________ ______________

C. DIAGNOSTIC TESTS

5. Plain X rays (cervical spine)

Normal

Degenerative changes

specify levels _____________________

Fracture/dislocation/subluxation

specify levels _____________________

Not indicated

6. Other specialized tests, specify:

____________________________________

D. DIAGNOSIS

7. Whiplash-associated disorder (WAD)

Grade I II III IV

8. Other injuries, specify: