XReport | Patient Data

Patient First Name

Patient Last Name

Patient DOB

Prescribing Doctor

Exam Date

Report Date

ADDITIONAL DETAILS (optional)

He also remembers his head hitting the:

headrest

airbag

door/door jamb

roof of the vehicle

IF OTHER THAN ABOVE, DESCRIBE

Do you remember your head being thrown one way and then the other (e.g. back and forth or side to side) at the moment of impact?

ADDITIONAL DETAILS (optional)

Just after the accident, he developed symptoms in the cervico-thoracic area including:

Uncheck any symptoms that are no longer present:

Please list all the things you continue to do even though doing them causes you discomfort

For example, I feel neck pain any time I lift my 3-year-old daughter.

Please list all the things you have stopped doing because doing them causes you too much discomfort (or you know they will)

For example, I no longer lift my 3-year-old daughter becuase it causes neck pain.

No prior accidents, trauma, or symptoms.

Prior accident or trauma but it did not cause any symptoms.

Prior accident or trauma with symptoms.

Prior symptoms without prior accident/trauma.

The most recent prior accident occurred approximately years and months ago

Statement to be included in the "Lack of a More Probable Alternative Explanation" section:

Check all that apply:

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