PHQ

Personal History Questionnaire

Dear Sir/Madam,

On this page, you will find our intake form, called a Personal History Questionnaire.

Please take the time to fill this out carefully and completely. Your attention to detail is important because this information contributes to a thorough and accurate Life Care Plan and/or Vocational Evaluation reports. These reports will be presented in court if your case goes to trial.

Note that there is an area near the end of this document should you require additional space to answer any of the questions in this form. For example, there are four spaces for your medications. If you take more than four, use the space at the end of this form to add information for the fifth and additional medications.

This form must be signed and dated at the bottom. If you have questions regarding the form, we would be happy to assist you. Please do not hesitate to contact our office by phone or email.

Thank you,
Lizette Mendoza
Life Care Plan Administrator

Personal History Questionnaire (PHQ)

"*" indicates required fields

I. Identifying Information

Name*

First Name * Middle Last Name *

Gender*

Date of Birth*

Country of Birth*

Year Immigrated to US*

Ethnicity*

Driver's License State

Primary Language*

Other Languages

Phone*

Secondary Phone

Email Address*

Present Address*

City/State*

Current Height/Weight*

Pre-injury Weight*

Military (Rank/Years)

Date of Injury/Type*

II. Family Information

Marital Status*

Current Partner Name*

Prior Spouse Name*

Children Information

Child's Name

Child's DOB

Other Parent Name

Resides With You?

III. Medical & Treatment Information

List any medical problems or conditions your doctors have diagnosed as a result of the injury in question*

List any prior accidents or pre-existing medical problems or conditions that predate the injury in question*

List your current treating AND evaluating physicians related to the injury or medical condition(s) in questions*

Name

Medical Specialty

Phone

Frequency of Treatment

List your current prescribed or over-the-counter medications related to the injury or condition in question*

Name

Purpose

Frequency Taken

Strength

IV. Exercise & Health

Did you exercise?*

If yes, what intensity?*

How often per week?*

Did or do you exercise?*

Did or do you use tobacco?*

If yes, which products?*

How many per day?*

For how many years?*

Year quit (if applicable)?*

Sexually active?*

Trying for pregnancy?*

Sexual dysfunction?*

If yes, which type?

Do you use a cane or walker?*

Do you use any braces or orthotics such as a knee brace or lumbar belt?*

Since the accident, have you fallen in your home or in the community?*

V. Living Situation Information

List the people who reside in your home, or anyone who comes to help you in your home*

Name

Relationship

Age

VI. Education Information

Did you graduate high school?*

If yes, which HS/Year?*

If not, what is the last grade completed?*

Did you obtain a GED?*

Special coursework or classes?*

Classes to learn English?*

College/Postsecondary Education and Training

College

Degree obtained/Date

Major

Minor (if applicable)

# of semesters completed

Grades (average)

Submit resume instead, IF APPLICABLE

Max. file size: 128 MB.

VII. Employment Information

Please fill out in lieu of a resume

Job Title

Employer City/State

Employer Name

Start/End Date

Starting Salary

Ending Salary

Responsibilities

Submit resume instead, IF APPLICABLE

Max. file size: 128 MB.

VIII. Household Activities

Rising from bed*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Rising from bed*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Sitting/standing from toilet*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Sitting/standing from toilet*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Toilet hygiene (wiping)*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Toilet hygiene (wiping)*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Entering/exiting shower*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Entering/exiting shower*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Washing body*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Washing body*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Dressing (socks, shoes)*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Dressing (socks, shoes)*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Dressing (pants, skirt)*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Dressing (pants, skirt)*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Dressing (fine dexterity)*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Dressing (fine dexterity)*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Dressing (upper body)*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Dressing (upper body)*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Preparing breakfast/lunch*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Preparing breakfast/lunch*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Preparing full dinner*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Preparing full dinner*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Opening jars/containers*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Opening jars/containers*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Using hands/fork to feed myself*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Using hands/fork to feed myself*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Shopping for groceries*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Shopping for groceries*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Unloading groceries from vehicle*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Unloading groceries from vehicle*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Putting groceries away*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Putting groceries away*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Running errands (bank, mail)*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Running errands (bank, mail)*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Dusting/wiping countertops*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Dusting/wiping countertops*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Loading/unloading dishwasher*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Loading/unloading dishwasher*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Sweeping/vacuuming/mopping*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Sweeping/vacuuming/mopping*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Cleaning bathroom/bathtub*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Cleaning bathroom/bathtub*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Taking out trash*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Taking out trash*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Laundering clothing*

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Laundering clothing*

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Mowing lawn (if applicable)

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Mowing lawn (if applicable)

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Raking leaves (if applicable)

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Raking leaves (if applicable)

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Shoveling snow (if applicable)

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Shoveling snow (if applicable)

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Cleaning gutters (if applicable)

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Cleaning gutters (if applicable)

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Driving a vehicle (if applicable)

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Driving a vehicle (if applicable)

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

Caring for children (if applicable)

Before being injured, I did this independently

On Occasion

Frequently

Did not do this

Caring for children (if applicable)

Now, I ...

Can still do this independently

Can do this in pain/less often

Need help/Cannot do

IX. Impairments

Please describe any impairments in the following categories related to the injury in question

Lifting*

How much weight?

Talking*

Did the accident affect your speech?

Hearing*

Did the accident affect your hearing?

Sitting*

How long before shifting positions?

Climbing*

Difficulty with stairs?

Balancing*

Instability/use of cane?

Stooping*

Painful or difficult

Driving*

How long?

Feeling*

Numbness/tingling, or weakness?

Reaching*

Difficult reaching forward/overhead?

Seeing*

Double or blurred vision or blind spots?

Standing*

How long before taking a break?

Walking*

How long before taking a break?

Bending*

Painful or difficult

Kneeling*

Painful or difficult

X. Pain Levels

Body Part Area
Code	Front	Code	Back
A1	Headaches/Migraines (front)	A2	Headaches/Migraines (back)
B1	Neck (front)	B2	Neck (back)
C1	Shoulders (front)	C2	Shoulders (back)
D1	Biceps	D2	Triceps
E1	Upper Torso (chest)	E3	Upper Torso (back)
E2	Lower Torso (front)	E4	Lower Torso (back)
F1	Forearms (top)	F2	Forearms (back)
G1	Wrists (top)	G2	Wrists (bottom)
H1	Hands (top)	H2	Hands (bottom)
I1	Genitalia	I2	Buttocks
J1	Quadriceps (front)	J2	Quadriceps (back)
K1	Shins	K2	Calves
L1	Feet/Ankles (top)	L2	Feet/Ankles (bottom)

Description
Pain Level	Description
0	Pain free.
1	Mild. Pain is very mild, barely noticeable. Most of the time you don’t think about it.
2	Minor pain. Annoying and may have occasional stronger twinges.
3	Uncomfortable. Pain is noticeable and distracting, however, you can adjust to it.
4	Moderate. The pain can be ignored for some time during activities.
5	Distracting. Mid-ranged pain. It can’t be ignored for more than a few minutes.
6	Distressing. Moderately strong, interferes in daily activities. Difficulty concentrating.
7	Severe. Pain that dominates your senses and limits your ability to perform activities.
8	Intensely Severe. Severely limited physical activity. Conversing requires great effort.
9	Excruciating. Unable to converse. Crying out and/or moaning uncontrollably.
10	Unspeakable. Bedridden, possibly delirious. Very few people experience this pain.

Please describe the following aspects for all body parts causing pain

Body Part

Constant/Occasional

Lowest # in Past 30 Days

Highest # in Past 30 Days

Any Numbness, Tingling, Burning?

XI. Cognitive Issues/Traumatic Brain Injury/Psychological

Please use this area to list cognitive issues as related to your injuries and associated limitations.

Short-term memory*

Mild

Moderate

Severe

Not Related

Long-term memory*

Mild

Moderate

Severe

Not Related

Attention and concentration*

Mild

Moderate

Severe

Not Related

Word finding issues*

Mild

Moderate

Severe

Not Related

Expressing ideas or communicating*

Mild

Moderate

Severe

Not Related

Difficulty understanding verbal or written information*

Mild

Moderate

Severe

Not Related

Anxiety, depression, PTSD*

Mild

Moderate

Severe

Not Related

Other

Please list

Cognitive/Psychological Impairment

Severity (Mild, Moderate, Severe)

XII. Additional Information

Please use this area to note any information that did not fit in the form above, or additional information you feel is important for us to know as related to your injuries and associated limitations

By typing or signing my name below, I affirm that all of the information provided on the previous pages of this document is true to the best of my knowledge.

Printed name if signed on behalf of the patient

If I am not the individual whose name and legal information is on this form, my name is

My relationship to the individual is

(parent, legal guardian, personal representative)

And I affirm that all of the information provided throughout this document is true to the best of my knowledge.

Electronic Signing Method*

I consent to sign electronically.

Sign with a mouse, stylus, or touchscreen

Sign by typing your full name with a keyboard

Signature*

Date of Signature*

reCAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

Discover the KWVRS Difference

Learn how our technology-driven approach and unmatched expertise can make a difference in your case.