Please take a few seconds to answer some research questions that will help other whiplash patients...

    1a.  What is your e-mail address?   (We need this data to ensure the research accuracy of this questionnaire.)

    1b. Were you injured in a car accident?

          Click Here Yes, the injury I'm describing is car accident related No, the injury I'm describing is related to something else

    1c. Which car accident related problem is the most disabling (prevents you from doing the things you need to or want to do)?

          Click Here Headaches Neck Pain Upper Back Pain Dizziness/Imbalance/Vertigo Pain in the Shoulder/Arm/Hand Tingling, nubness, or weakness in the forearm, wrist, or hand Low Back/Hip Pain Thight/Leg/Foot Pain or Numbness/Tingling Other

    2.  What does this car accident related problem prevent you from doing?  (As much as you could before the accident)

    Type a 1, 2, 3 or 4 next to each category to describe what your most disabling problem prevents you from doing:

    1=No car accident related problems with this activity

    2=Some problems, but I can usually do this activity

    3=Significant problems, I avoid this activity

    4=I can't do this activity because of my most disabling car accident problem

    Walking     Running    Climbing Stairs     Lifting or Carrying Groceries

    Reading     Sitting      Standing               Driving

    Bending     Chewing   Sleeping                Looking Right or Left

    Gripping Things

    3.  How often do you have problems doing the things you described above?

    Click Here Once a month or less A few times a month A few times a week A few times a day Always have problems

    4. Did you have this problem before the car accident?

    Click Here No Yes, Accident Made it Worse Yes, But Accident Didn't Change it Much

    5. How long has it been since the car accident that caused this problem?

    Click Here 0-3 months 3 months to a year 1-3 years more than 3 years

    6. What part of the world did you have your car accident?

    State (USA)    Country (Outside USA Only) 

    7.  How did you car get hit?        

    Front-Head On            Front Quarter Panel-NOT Head On
    Driver's Side               Passenger's Side
    Rear Quarter Panel    Rear-end
    None of These

    I was a pedestrian
    Other (On bike, motorcycle, etc...)

    8.  How much damage was there to your car?

    Click Here 0-$500 500-$1,500 $1,500-$2,500 $2,500-$5,000 More Than $5,000      

      (Pressing Submit with all questions answered will bring you to the interactive whiplash machine...)