Injury Questionnaire

Please describe what happened.
Please describe any pain, numbness, and other difficulties.
Describe how your injury limits your ability to work or perform household tasks.
Enter a number from 0 to 10 (0 = No pain and 10 = Severe pain)
Do you have days with no pain?
Answer in minutes or hours (for example, 10 minutes, 1 hour, etc)
Answer in minutes or hours (for example, 10 minutes, 1 hour, etc)
Answer in minutes or hours (for example, 10 minutes, 1 hour, etc)
Please enter any additional information you would like me to know.