Click Here Yes No   If you answered no to this question, then click here...

    If you answered yes, continue...

What is your e-mail address?   (We need this data to ensure the research accuracy of this questionnaire.)

What part of the world do you live?

    Click Here USA Africa Asia Austrailia/New Zealand Canada Central America Eastern Europe Europe Mexico South America Other

What's your educational level?

    Click here Grade School High School Diploma Some College Vocational Training or Apprenticeship College Degree Post Graduate Degree PhD, MD, DO, or Other Doctotate Level Degree

Click Here Under 18 19-30 30-40 40-50 50-65 65+

What is your gender?

Click here Male Female

The next several questions pertain to your injuries...

Front-Head On
Front Quarter Panel-NOT Head On
Driver's Side
Passenger's Side
Rear Quarter Panel
Rear-end
None of These

I was a pedestrian
Other (On bike, motorcycle, etc...)

Click Here Less than 3 months 3 months to 1 year 1-2 years 2-3 years 3-5 years 5-10 years 10-20 years 20+ years

Click Here Under $500 $500-$1,500 $1,500-$2,500 $2,500-$5,000 $5,000+

How often did you have pain before this accident?

  Click Here Almost Never A few times a month A few times a week A few times a day Constantly

Were you in treatment before the accident, for the areas that were injured in the accident?

  Click Here No Yes

How was your health before the accident?

  Click Here Excellent Good Fair Poor

What types of treatment are the most effective for your car crash related pain?

  Please type a 1,2,3, or 4 (no zero's) in the box to the left of all treatments you have tried

  for this problem.

  1=Very Effective

  2=Effective

  3=Not Effective

  4=Made Me Worse

How severe has your car crash related pain been this past month?

  Click Here Very Mild Mild Moderate Severe Very Severe

What type of doctors or medical provider's have you seen for this problem?

  Please rate the effectiveness of all doctors or therapists you have seen  for this

  problem by typing a 1,2,3, or 4 (no zero's) in the box to the left.   If you've seen two of the

  same type and one was more effective than the other, rate the better experience.

  1=Excellent-I got much better with this doctor or therapist

  2=Good-I improved with this doctor or therapist

  3=Fair-I didn't get much better with this doctor or therapist

  4=Poor-Made Me Worse

Which doctors or therapists were the most knowledgeable about your problems?

  Please type a 1,2,3, or 4 (no zero's) in the box to the left of all doctors or therapists you have

  seen  for this problem.   If you've seen two of the same type and one was more

  effective than the other, rate the better experience.

  1=Really knew a lot about my injuries

  2=Knew something about my injuries

  3=Didn't seem to know about my injuries

  4=Didn't seem to have a clue

If it's not on the list, enter it here...

How would you rate this company on their handling of your medical claim?

       (Paying medical bills, handling the injury claim, fairness, etc)

         Click Here Excellent Good Fair Poor Unacceptable Paying Cash

Do you have or are you considering hiring an attorney, and if so, why?

       Click Here Yes, to represent my interests Yes, friend or family member suggested it Yes, insurance company problems Yes, other reasons Yes, had an attorney, but case now settled No, don't have one and have no plans to get one

What state do you have your car insurance? (The company paying your medical bills.)

        Type two letter postal code...         Outside USA

How many different things have your medical providers told you about whiplash since your injury?

        Click Here I have heard one consistent message about this illness I have heard a few different things from different providers All of my medical providers seem to tell me something different Nobody has told me anything about whiplash