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:
