Since the accident, what symptoms have you experienced or noticed worsening? (select all that apply)

Did any of these symptoms begin or significantly worsen as a result of the accident?

YES

NO

Not Sure

Are you experiencing pain that radiates into your upper extremities?

Yes, into my arms

Yes, into my hands or fingers

Not Sure

NO

Are you experiencing pain that radiates into your lower extremities?

Yes, into my legs

Yes, into my feet or toes

Not sure

No

Are you experiencing any of the following in your upper extremities? (Select all)

Numbness or tingling

Muscle weakness

Pain or discomfort

None of the above

Are you experiencing any of the following in your lower extremities? (select all that apply)

Numbness or tingling

Muscle weakness

Pain or discomfort

None of the above

Are you currently pursuing legal action or a personal injury claim?

YES

NO

NOT SURE

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