West Palm Beach Car accident - Medical Examination Questionnaire

MEDICAL EXAMINATION
QUESTIONNAIRE

Name of person examined?:________________________________________

Date of Examination?:_______________________ Time:________________

Examining Physician?:____________________________________________

Address of Physician?:____________________________________________

What time did you arrive?:_________________________________________

What time did you leave?: _________________________________________

Did you see the Doctor immediately upon your arrival?:__________________

How long did you wait?:___________________________________________

Were you questioned by a nurse prior to seeing the Doctor?: ______________

If "Yes", list each question asked and the answers given:

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Were you asked to sign anything?:___________________________________

If so what?:_____________________________________________________

Did you sign it?:_________________________________________________

What questions did the doctor ask you and what answers did you give?:
List each question and answer:

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Did he write down your answers?____________________________________

Did it appear that he made notes of, or that he dictated substantially everything you told him?___________________________________________________________

What examination did he conduct? (Give detailed step by step explanation):

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How long were you actually with the doctor?___________________________

How much of this time was "questions and answers?"____________________

How much of this time was actually examination?_______________________

Were x-rays taken? _______________________________________________

If so, where?_______________________________________________

By whom? ________________________________________________

How many? _______________________________________________

Of what parts of your body?___________________________________

How? (front, back, lying, standing, etc.)___________________________
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What tests were performed?

EKG?____________________________________________________

Blood pressure?____________________________________________

Temperature?______________________________________________

Listened to chest with stethoscope?_____________________________

Bend to touch floor?_________ How far could you bend?___________

Did it hurt, and if so, where?__________________________________

Was a finger to nose test taken?_______________________________

Could you do it?_______________ The first time? ________________

Did it hurt, and if so, where?__________________________________

Was neck test taken?____________. Rotation?___________________

Flexion-Extension-(backwards and forwards)?____________________

Was there limitation?________________________________________

How much?_______________________________________________

Did it hurt, and if so, where?__________________________________

Did the doctor take any measurements of any parts of the body?______

If so, of what parts of the body? ________________________________
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Did the doctor give you the pin-prick test? _______________________

If so, did you notice any numbness? (If so, describe):

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List below any comments by the doctor during examination or tests, concerning:

1. Patient's condition: ______________________________________________
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2. Prognosis:_____________________________________________________
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3. Lawsuit: ______________________________________________________
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4. Opinion of your doctors:__________________________________________
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5. Limitations: ___________________________________________________
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6. Suitability for employment:_______________________________________
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7. Other comments: _______________________________________________
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Any Other Information______________________________________________
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