Electrical Injury Survey Form

Instructions:

Please fill in the form below to the best of your abilities. It should take approximately 10-20 minutes to complete. Most answers require that you click the correct choice or choices. Please don't feel the need to write long essays even though the space is provided.

Read the brief instructions for each section and then answer as accurately as is possible.

Don't guess, but,
where possible rely on your memory, information given to you by your doctor, or input from witnesses.

This information is being used in a study that is conducted by Dr. Michael Morse at the University of San Diego. The study will statistically evaluate electrical injury.

(NOTE: Dr. Morse is a Ph.D. in Biomedical Engineering, a faculty member in Electrical Engineering, has been researching electric shock for over ten years, and is a recognized expert in the area of electrical injury. Dr. Morse is NOT a physician and cannot provide medical advice.)

Your individual responses will be kept confidential. NO identifying information will be kept with your survey submission.

FILLING OUT SURVEY MORE THAN ONCE: You may fill out the Survey more than once if you have more information to add since you last completed the survey. If you fill out the survey more than once, make sure that you indicate that you have filled out the survey before. Also, you MUST enter the same Date of Injury and the same zipcode that you used when you previously completed the survey.

Please only submit completed surveys. Incomplete surveys are discarded.

By providing accurate and complete information, we hope to be able to assist individuals such as yourself to understand the effects of electric shock.

The study results will be made available to you (or your physician) by e-mail if you have provided your email address in the box below. (Study results will only be made available after accepted for peer reviewed publication.)

Please Enter Your E-mail Address (Optional):

(Your email address will only be used to provide you with updates on the status of this project)

Thank you very much for your time!

General Information:

Click on box if you have filled out this survey before:
Enter your Zipcode here:

About you:

Gender: Female Male Marital Status at the time of injury: Single Married Divorced Widowed	Race: Caucasion African-American Asian Hispanic American Indian Other
Age at time of injury:	Profession at the time of your injury: (Examples: student, homemaker, truck driver):

Litigation relating to your injury:

No litigation or workers compensation claim associated with this injury (past or anticipated)
Litigation has been completed
Currently being litigated
Workman's Compensation Claim only

Other Litigation:

I have never sued anyone or filed a worker's compensation claim.
I have sued for a prior injury
I have been involved in more than one prior lawsuit..

About your injury:

Date of injury (MM/DD/YY):
(Please use this exact format for date)

Click where injury occurred:
Home
Work

School
Recreation
Other

Circumstances of injury (example: "In bathtub while taking a bath"):

Did you lose consciousness at the time of the injury?
No loss of consciousness
Loss of Consciousness of less than 1 minute
Longer loss of consciousness

Duration of Contact:
Less than 1/2 second (An instant)
1/2 - 1 second
1-5 seconds
5-30 seconds
30 seconds to 1 minute
Greater than 1 minute

Voltage of Contact
110-120 Volts (Household)
220-240 Volts (Light industrial)
440-480 Volts (Industrial)
1000-2500 Volts
2501-5000 Volts
5001-10000 Volts (Power line)
Greater than 10000 Volts
If you are not sure of the voltage, click the one below that seems most correct:
Home appliance other than electric oven, electric dryer
Electric dryer, electric oven
Shock from Telephone
Lightning Strike
Static electricity
DC or Capacitive Discharge

Where do you think it is most likely that electricity "ENTERED" your body?
Do Not know
Left Fingers
Right Fingers
Left Hand
Right Hand
Both Hands
Left Arm
Right Arm
Neck
Top/Back of Head
Face
Upper Torso / Chest
Stomach Level
Upper Back
Lower Back
Groin
Buttocks
Left Leg
Right Leg
Left Foot
Right Foot
Both Feet
Multiple Entry Points

Which of the following best describes what happened at the point where the electricity entered your body?
No marking on entrance
Reddening of skin only
Blistering of skin
Deep tissue burns

Where do you think it is most likely that electricity "EXITED" your body?
Do Not know
Left Fingers
Right Fingers
Left Hand
Right Hand
Both Hands
Left Arm
Right Arm
Neck
Top/Back of Head
Face
Upper Torso
Stomach Level
Upper Back
Lower Back
Groin
Buttocks
Left Leg
Right Leg
Left Foot
Right Foot

Both Feet
Multiple Exit Points

Which best describes what happened at the point where electricity exited your body?
No marking on entrance
Reddening of skin only
Blistering of skin
Deep tissue burns

In the space below DESCRIBE WHAT THE SHOCK YOU RECEIVED FELT LIKE.

In the space below feel free to provide a more detailed description of the circumstances under which you were shocked. For example, if you were shocked outdoors, describe the weather and the ground conditions. You might describe the shoes and clothes you were wearing.

Symptoms and Diagnoses:

Directions: For each ROW, check each box that applies. The directions for each COLUMN are as follows:

"Pre-existing" Column: Check those boxes for symptoms (or diagnoses) that you had prior to the electrical contact that is the subject of this survey.
"Immediate -- First 48 Hours" Column: Check those boxes for symptoms (or diagnoses) that started in the first 48 hours following your electrical contact
"First Three Week" column: Check those boxes for symptoms (or diagnoses) that either ORIGINATED in the first three weeks or CONTINUED into the first three weeks.
"First Six Months" column: Check those boxes for symptoms (or diagnoses) that either ORIGINATED in the first six months or CONTINUED into the first six months following the electrical contact.
">6 Months" Column: Check those boxes for symptoms (or diagnoses) that either ORIGINATED more than six months after the shock or CONTINUED beyond six months following the shock.

Check all the boxes that apply:

Be thorough and accurate in your responses:

To complete this survey, you MUST press the "SUBMIT" button AT THE BOTTOM of the page. (You are encouraged to enter further information in the boxes below before pressing the SUBMIT button.)

Additional Information:

In the text boxes below, please provide any additional information that is pertinent to the question asked above the box.

1. List any other information that you think may be pertinent about your medical history:

2. List any other symptoms or diagnoses that arose or were told to you within the first 48 hours following your electrical injury:

3. List any other symptoms or diagnoses which arose OR continued between 48 hours and three weeks following your electrical injury

4. List any other symptoms or diagnoses which arose or continued more than three weeks and less than six months following your injury:

5. List any other symptoms or diagnoses which arose or continued for more than six months following your injury. Feel free to describe symptoms that still exist is more than six months following your electrical contact:

VI. Other Information:

Please provide any other information that you feel may be pertinent to understanding your electrical injury.

If you wish to recommend any medical facilities or physicians in your area that you think might be able to help others with electrical injuries, feel free to do so here. Also, feel free to list any lawyers who you would recommend to others in your area. Dr. Morse will be happy to pass that information along.

Please also feel free to make suggestions to improve this survey or just general comments that you would like for Dr. Morse to read.

REMEMBER: To enter your survey, you MUST click

the SUBMIT button below.

Click Submit to send survey

Symptoms (What you felt)	Pre-existing	Immediate -- First 48 hours	First Three Weeks	First 6 Months	> 6 Months
General exhaustion
General physical weakness
Muscle Aches
Muscle Spasms or Twitches
Muscle Cramps
Frequent or excessive constipation
Loss of Bowel Control
Loss of Bladder Control
Unusual anxiety
Loss of normal physical coordination
Loss of normal communication skills
Reduced attention span/lack of concentration
Fear of electricity
Fear of crowds
Other intense or unexplainable fears
Unexplained sadness
Crying Spells
Panic attacks
Extreme physical sensitivity
Extreme emotional sensitivity
General forgetfulness
No Recollection of the electrical accident	N/A
Personality or Mood Swings
General fatigue
Severe menstrual cramps
Easily confused
Cognitive problems (lack or loss of reasoning skills)
Chest pains
Weight gain and/or loss
Unexplained moodiness
Excessive Thirst
Hearing Loss
Ringing in ears
Dry Eyes
Generalized Headaches
Severe Headache or migraine
Long Term Memory Loss (distant events)
Short Term Memory Loss (recent events)
Numbness in Hands
Numbness in Arms
Numbness in Legs
Back Problems
Loss of ability to talk
Loss of ability to talk
Dizziness
Nightmares
Insomnia (sleep disorders)
Excessive Sweating
Weakness in joints
Stiffness in joints
Convulsions or seizures
Sensitivity to Light
Weakened Grip
Tingling in hands
Tingling in arms
Tingling in legs
Pins and Needles in Hands
Paralysis (generalized)
Chronic pain (generalized)
Increasee temper (unexplained)
Inability to cope with life in general
Sexual dysfunction
Heart Palpitations
General Disorientation
Dental Problems (Broken teeth or teeth hurt)
Blurred Vision
Physical Tremors
Aggressive Behavior
Feeling of hopelessness
Loss of appetite
Lack of motivation

Diagnoses (What your doctor told you)	Pre-existing	Immediate -- First 48 hours	First Three Weeks	First 6 Months	> 6 Months
Tachycardia (High heart rate)
Bradycardia (Low heart rate)
Ventricular Fibrillation
Other irregular EKG or heart arrythmia
Diagnosis of TMJ (Temporomandibular Joint Disorder)
Reflex Sympathetic Dystrophy (RSD)
High Blood Pressure
Brain damage as measured by EEG
Neural damage as measured by a positive Nerve Conduction Study -- (Left side)
Neural damage as measured by a positive Nerve Conduction Study -- (Right Side)
Diagnosed Carpal Tunnel Syndrome (Left Hand)
Diagnosed Carpal Tunnel Syndrome (Right Hand)
Kidney Problems (medically diagnosed)
Post Traumatic Stress Disorder (PTSD)
Cancer
Muscular Dystrophy
Brain Tumor
Wounds requiring amputation
Arthritis
Concussion
Broken Arm(s)
Broken Leg(s)
Other Broken bone(s)
Fibromyalgia
First Degree Burns	N/A
Second Degree Burns	N/A
Third Degree Burns	N/A
Parasthesias
Abnormal MRI
Abnormal CAT scan
Coma
Clinical Depression
Organic brain disorder
Psychosomatic Disorder
Somatisized Symptoms
Rotator Cuff Injury
Brachial Plexus Injury
Chronic Pain Syndrome
Diabetes
Other Neurological Disorder(s)
Seizure Disorder

Social and Family	Pre-existing (Pre)	Immediate -- First 48 hours (init)	First Three Weeks	First 6 Months	> 6 Months
Marital or Family problems existed prior to electrical contact
Marital or Family problems that did not exist prior to electrical contact	N/A
Two or more divorces prior to electrical contact
Divorce not anticipated prior to electrical injury	N/A
Loss of more than three jobs in five years prior to electrical contact
Loss of employment after electrical injury