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Active Restoration Assessment Questionnaire |
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Identifying Information
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First Name:
Last Name:
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Marital Status:Single Married
Divorced Separated
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Date of Birth:
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Are you right handed left handed
ambidextrous:
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Injury Details
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Date of Injury/Accident:
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Have you had any previous or subsequent injuries, including any other illnesses, work-related, recreational or motor vehicle injuries?
Yes No
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If yes, Please describe including date of incident:
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Please describe how your recent injury/disability occurred:
Incident at Work
Motor Vehicle Accident
Were you the: Driver Front Passenger
Left Rear Pass Right Rear Pass
Pedestrian Other
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Were you wearing your seatbelt? Yes
No
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What type of vehicle were you in? Year: Make:
Model:
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What other vehicles were involved (to the best of your recollection)?
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What were the travelling speeds at the time of impact? Your Vehicle
Other Vehicle
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Please describe the weather conditions:
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Did any air bags deploy? Yes No
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Areas of impact to the vehicles?
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Were the vehicles drivable? Yes No
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Amount of damage to your vehicle:
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Did you hit your head on impact? Yes No
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Did you lose consciousness? Yes No
- If yes, for how long?
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What problems or complaints did you have immediately following the accident?
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Were you able to exit the vehicle on your own? Yes
No Not applicable
If no, what assistance did you get?
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Who attended the accident scene? police
ambulance fire
- If other :
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Did you go to hospital? Yes No
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If you did go to the hospital:
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How did you get there?
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How long were you in hospital?
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What tests were conducted? None
X-ray MRI
CT Scan Bone Scan
Ultrasound - If Other:
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Describe results:
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If you did not go to hospital
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How did you get home?
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When did you attend your doctor’s office?
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Doctor’s Name:
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Doctors Phone No.:
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Was this your usual family doctor? Yes
No - If yes,
How many years have you had this family doctor?
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Have you seen any other Healthcare providers or had any other assessments? Yes
No
If yes, please list:
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Present complaints
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Have you had physiotherapy? Yes No
If yes - Date started: Date ended:
Where?
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Have you been receiving Exercise program
Massage Chiro -
Other:
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Do you have a driver’s license? Yes
No
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Are you driving at present? Yes No
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Work & Educational History
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Employment Status at time of accident:
Student Volunteer
Homemaker Unemployed
Employed Full time Self-employed
Retired Employed part time
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Who were you employed by when you were injured?
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How long had you been employed there?Years
Months
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What was your job title?
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What did this job involve? (list primary demands)
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What type of work have you performed previously? (past 5 years)
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What is your level of education?
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Are you currently working? Yes No
If yes, where?and hours worked per week?
Are you on regular duties? Yes No
Modified
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Social & Functional History
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Address of residence:
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Type of Home: Apartment
House Townhouse Multi-level
Bungalow Basement Apartment
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Number of bedrooms? Basement laundry?
Yes No
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Who lives with you? (e.g. spouse, # of children & ages)
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What household tasks were you responsible for prior to your injury?
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Did anyone share these responsibilities with you?
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What exterior home maintenance tasks were you responsible for prior to your injury?
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Did anyone share these responsibilities with you?Yes
No
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Have you resumed your housekeeping & home maintenance activities as described above?
Yes No
If no, please describe which you are still unable to do:
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Are you involved in any significant recreational Pursuits? Yes
No
If yes, please describe:
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Do you smoke? Yes Reformed
No
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How many alcoholic beverages do you consume per day/week?
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How many caffeinated beverages do you consume per day/week?
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Medical History
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Have you had any medical hospitalizations? Yes
No
If yes, please describe:
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Have you had any operations? Yes No
If yes, please describe:
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Are you taking any prescribed medications at present?Yes
No
If yes, please list them:
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Please describe any allergies:
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Do you have any other medical problems? Yes
No
If yes, please describe:
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Do any diseases run in your family? Yes
No
If yes, please describe:
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Completed by: Date:
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