Whiplash Injury Questionnaire

Please take a few minutes to help other patients by allowing us to fully understand whiplash.

These few questions will enable our research group to treat whiplash patients more effectively.

1a. Have you ever had an injury in a car crash?

If you answered no to this question, then click here...

If you answered yes, continue...

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

2. What part of the world do you live?

3. What's your educational level?

4. How old are you?

What is your gender?

The next several questions pertain to your injuries...

How did your 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...)

How long have you had whiplash pain?

How much money did it cost to fix your car or vehicle?

Which symptoms have you had this last month that are related to the car or vehicle crash?

Pain in the Front of the Neck     Pain in the Back of the Neck                   
Headaches in the Top of the Head  Headaches in the Whole Head               
Chest Pain                        Upper Back Pain                                        
Hip Pain                          Numbness, Tingling in the Leg to Foot 
Problems Sleeping                 Problems Thinking or Remembering

Dizziness, Off-Balance, Vertigo

    Numbness, Tingling in the Arm to Hand     Lower Back Pain

    Headaches in the Back of the Head         Headaches Behind the Eyes

    Headaches in the Forehead                 Headaches in the Temple

Question #5 only pertains to your condition before the accident...

5. How often did you have pain before this accident?

Were you in treatment before the accident, for the areas that were injured in the accident?

How was your health before the accident?

Questions 6-13 pertain to your car crash related problems...

6. What types of treatment are the most effective for your car crash related pain?

Please type a 1,2,3, or 4 (no zero's) in the box to the left of all treatments you have tried

for this problem.

1=Very Effective

2=Effective

3=Not Effective

4=Made Me Worse

Chiropractic Manipulation  Massage           
Heat                       Cold                            
Electrical Treatments      MedX Neck/Back Machines                    
Acupuncture                Anti-Inflammatories             
Sleep Medications          Rolfing                   
Physical Therapy           Strengthening Exercises              
Posture Exercises          Biofeedback

Muscle Relaxers            Narcotic Pills

Surgery                    DO/Osteopathic Manipulation

Range of Motion            Traction

Injections                 Neck Brace/Back Brace

Psychological Counseling

7. How severe has your car crash related pain been this past month?

8. What type of doctors or medical provider's have you seen for this problem?

Please rate the effectiveness of all doctors or therapists you have seen for this

problem by typing a 1,2,3, or 4 (no zero's) in the box to the left. If you've seen two of the

same type and one was more effective than the other, rate the better experience.

1=Excellent-I got much better with this doctor or therapist

2=Good-I improved with this doctor or therapist

3=Fair-I didn't get much better with this doctor or therapist

4=Poor-Made Me Worse

Family Doctor Orthopedic Specialist Neurologist

Physical Medicine and Rehab Doctor Physical Therapist (Not MD/DO)

Chiropractor Massage Therapist Other

TMJ Dentist Psychologist Neuropsychologist

9. Which doctors or therapists were the most knowledgeable about your problems?

Please type a 1,2,3, or 4 (no zero's) in the box to the left of all doctors or therapists you have

seen for this problem. If you've seen two of the same type and one was more

effective than the other, rate the better experience.

1=Really knew a lot about my injuries

2=Knew something about my injuries

3=Didn't seem to know about my injuries

4=Didn't seem to have a clue

Family Doctor Orthopedic Specialist Neurologist

Physical Medicine and Rehab Doctor Physical Therapist (Not MD/DO)

Chiropractor Massage Therapist Other

TMJ Dentist Psychologist Neuropsychologist

10. What's the name of the insurance company paying your medical bills?

If it's not on the list, enter it here...

How would you rate this company on their handling of your medical claim?

(Paying medical bills, handling the injury claim, fairness, etc)

11. Do you have or are you considering hiring an attorney, and if so, why?

12. What state do you have your car insurance? (The company paying your medical bills.)

Type two letter postal code... Outside USA

13. How would you rate your family doctor's knowledge in treating strep throat and

other common, everyday illnesses?

14. How many different things have your medical providers told you about whiplash

since your injury?

Thanks for taking the time to fill this out...your responses will help us fully understand whiplash

and will help future patients.

Whiplash Injury Questionnaire

Last revised: October 21, 2007