RapidLink Medical Group PC

WELCOME

Welcome · Bienvenido · Byenveni

Please choose your language

This secure form takes about 10 minutes. Your answers go directly to your medical team and become part of your medical record, so please answer as completely and accurately as you can, in your own words, without exaggerating. You can move back and forth between pages until you press send.

⏱ About 10 minutes

Your answers save automatically on this device — you can close this page and pick up right where you left off.

YOUR INFORMATION

First name *

Middle name (optional)

Last name *

Enter the name exactly as it appears on your driver's license or insurance card.

Date of birth

Sex

1 · GENERAL MEDICAL HISTORY

Prior motor vehicle accidents (or tick none) No prior motor vehicle accidents Past medical history (or tick none) None Past surgical history (or tick none) None Home medications (before the accident) (or tick none) None

Do you take a blood thinner, or aspirin, every day?

For example: aspirin (including baby aspirin 81 mg), Plavix (clopidogrel), Brilinta (ticagrelor), Eliquis (apixaban), Xarelto (rivaroxaban), warfarin (Coumadin)

Allergies (or tick none) No known allergies

3 · BEFORE THE ACCIDENT

I was fully independent, active, and had no physical limitations before the accident I was caring for children / dependents without difficulty

Employment at time of accident

Your job

Any pain ANYWHERE in your body before this accident?

Before this accident, had you ever injured or been treated (chiropractor, physical therapy, etc.) for your neck, back, or any area that hurts now?

4 · THE ACCIDENT

What kind of accident was it?

In your own words, tell the doctor step by step how the accident happened, so the doctor can picture it as if they were there.

Please include: where you were sitting and which way you were going · whether you were stopped or moving · where the other vehicle came from and what part of your vehicle it hit · what your vehicle did after the hit (pushed forward, spun around, rolled over, or hit something else). Some of this is asked again later with choices — your own story still helps the doctor understand. Example: “I was driving and stopped at a red light. A car coming from behind hit the back of my car and pushed me into the car in front of me.”

Type of collision

You were the

What kind of vehicle were you in?

What kind of vehicle hit you?

Where did the accident happen?

What was the vehicle you were in doing?

Where did the other vehicle come from?

What part of the other vehicle hit?

What part of your vehicle was hit?

Your vehicle was

Your speed

Other vehicle speed

Seatbelt worn

Seatbelt mark/bruise on chest or belly?

Airbag deployed?

Damage to the vehicle you were in

Describe the damage

After the accident, was the car towed or driven away?

After the first hit, did your vehicle then hit anything else?

Did you see it coming, or were you caught off guard?

At the moment of impact, where was your head facing?

Where was your headrest (the padded part behind your head)?

Hit your head?

If yes, on what

Lost consciousness?

Getting out of the vehicle

Did any of these happen? (check all that apply)

I was thrown out of the vehicle I had to be cut out or pulled out by rescuers Someone else was seriously hurt or killed The part of the car where I sat was crushed inward

None of these happened to me

Is there any part of the accident (or right before or after it) that you cannot remember?

Have you vomited since the accident?

Did you have a seizure (convulsion) at the scene?

5 · CARE SO FAR

Did you go to the hospital, urgent care, or see any doctor the SAME DAY?

Did EMS (paramedics) come and check you at the scene?

Imaging / tests already done (check all)

X-ray CT scan MRI Ultrasound

Who have you seen for ongoing treatment since the accident?

Since the accident, has anything else happened that injured you or made your symptoms worse - another accident, a fall, a work injury, or anything similar?

New medications since the accident (or tick none) No new medications since the accident

6 · SAFETY QUESTIONS

If you have ANY of these right now, tell us immediately — and if it is severe or getting worse, do not wait for us: call 911 or go to the nearest emergency room. Otherwise, check any that apply. If you have none, that is good — leave them all unchecked.

7 · WHERE DOES IT HURT?

Check every area that hurts (a set of questions opens for each one)

Front

Back

Tap every place on the body that hurts — it lights up gold and its questions open below. If it hurts on both the front and the back, it lights up on both pictures. Tap again to remove.

Prefer a checklist instead? Tap here

Do you have any bleeding or an open wound from the accident?

Other symptoms right after or in the days after — anything not already covered above (optional)

YOUR HEAD AND FACE

Since the accident, have you had any of these? Check all that apply — or tick the box at the bottom of the page if you have had none of them. Headaches Problems with my face, eyes, ears, nose, jaw, mouth or teeth

These are problems people often forget to mention because they are not painful. Please check anything that is NEW since the accident — anything you believe started because of it.

Your face — movement and feeling

Weakness or drooping of my face

Your ears, hearing and balance

Hearing worse

Ringing in the ears

Ringing that pulses with my heartbeat

Room spins when I move my head

Off balance / unsteady

Ear pain or bleeding from ear

Your eyes and vision

Blurry vision

Seeing double

Hard to focus or read up close

Part of my vision seems missing

Eye pain

Light bothers my eyes more

Your nose, smell and taste

Cannot smell, or smells are different

Cannot taste, or food tastes different

Your jaw

Jaw pain

Jaw clicks or pops

Cannot open my mouth all the way

Your mouth and teeth

My bite feels different

Loose, broken, or missing teeth

Urination

Hard to start, or bladder does not empty

Pain when urinating

Pain or swelling in the testicles

Tell us more in your own words — how often does it happen, when does it happen, and how long does it last?

8 · DAILY LIFE & WORK

In your own words — what can you no longer do, and how has daily life changed? (optional) Areas affected (check all)

Walking / standing / sitting / driving Lifting and carrying Bathing / dressing / self-care Household & work tasks Exercise / hobbies Caring for children Now rely on others

My daily activities have NOT been affected Sleep My sleep is fine — no problems since the accident

Work impact

Number of days missed

Anything else about how the accident changed your work (optional)

9 · EMOTIONS & MENTAL HEALTH SINCE THE ACCIDENT

These questions are about how the accident affected you emotionally. Please answer honestly — no need to overstate anything. If several apply to you, your care team will arrange support.

Since the accident, have you had any of these that you did NOT have before? (check all) I have NOT had any of these

You feel these are caused by: (check all)

The ongoing pain & limitations The traumatic event itself Not being able to work / money stress Losing the vehicle Something else — I will describe it

These feelings began

Currently seeing a mental health provider?

Anything else in your own words (optional)

9B · SHORT STANDARD QUESTIONNAIRES

These short standard questionnaires are used by doctors everywhere. Answer for the LAST TWO WEEKS (the last month for the final five). There are no right or wrong answers.

10 · MRI SAFETY QUESTIONS

If the doctor orders an MRI for you, these answers must be complete. Please do not skip them — they are very important, and answering them now can save you days of waiting for your scan.

Your height and weight

Which measurements do you use?

How uncomfortable do you feel in small, closed spaces? (0 = not at all, 10 = extremely) Have you ever had metal in your eyes or anywhere in your body? (shrapnel, a bullet, metal fragments from grinding or welding) Do you have anything inside your body that you were not born with? (medication pump, stimulator, aneurysm clip, shunt, stent, glucose monitor) Do you have a pacemaker or a defibrillator? Have you had surgery on your head, heart, ear, eye — or on the part of your body that hurts? Do you wear any patch or pump that gives you medicine? (pain patch, insulin, Neulasta) Do you need any help getting to the machine or onto it? (walker, wheelchair, crutches, interpreter)

Scheduling your imaging and specialist appointments

What weekdays and what times are you available for imaging and specialist appointments? Can the scheduling team call you any time, or are there times you cannot answer your phone?

11 · ANYTHING ELSE

Anything else you want your care team to know — about how you are feeling mentally or physically, or anything we did not ask above (optional).

12 · SIGN & SUBMIT

I certify that the information I have provided is true and accurate to the best of my knowledge.

Please sign below with your finger or mouse: (required to send)

DONE?

When you have answered everything above and signed, tap the green button to send your answers to your care team.

Thank you — your answers have been received.

First, a member of our team who speaks your language will call you to go over your answers and fill in any details. After that, RapidLink Medical Group will reach out to schedule your live video visit with the doctor. It is simple: you will receive a link to click, and an interpreter will be available if you need one.

Before your video visit, please have:

A good internet connection
A quiet place where you will not be interrupted
A working camera
Please SET THE PHONE DOWN in front of you, so the doctor can see you fully during the exam

You can join from your phone, laptop, or any device.

Please set aside about 30 minutes to an hour for the visit. It does not have to be during working hours — evening appointments after work are welcome.

WELCOME

YOUR INFORMATION

YOUR SIGNATURE

YOUR INFORMATION

1 · GENERAL MEDICAL HISTORY

3 · BEFORE THE ACCIDENT

4 · THE ACCIDENT

5 · CARE SO FAR

6 · SAFETY QUESTIONS

7 · WHERE DOES IT HURT?

YOUR HEAD AND FACE

8 · DAILY LIFE & WORK

9 · EMOTIONS & MENTAL HEALTH SINCE THE ACCIDENT

9B · SHORT STANDARD QUESTIONNAIRES

10 · MRI SAFETY QUESTIONS

11 · ANYTHING ELSE

12 · SIGN & SUBMIT

DONE?

Thank you — your answers have been received.