Electrical Injury Survey Form
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,
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
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.)
Thank you very much for your time!
Click on box if you have
filled out this survey before:
Enter your Zipcode here:
Marital Status at the time of injury:
|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..
|Date of injury (MM/DD/YY):
(Please use this exact format for date)
Click where injury occurred:
|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
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)
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
DC or Capacitive Discharge
Where do you think it is most likely that electricity "ENTERED"
Which of the following best describes what happened at the point
where the electricity entered your body?
Where do you think it is most likely that electricity "EXITED" your
Which best describes what happened at the point where electricity
exited your body?
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.
Directions: For each ROW, check each box that applies. The directions for each COLUMN are as follows:
Check all the boxes that apply:
Be thorough and accurate in your responses:
|Symptoms (What you felt)||Pre-existing||Immediate -- First 48 hours||First Three Weeks||First 6 Months||> 6 Months|
|General physical weakness|
|Muscle Spasms or Twitches|
|Frequent or excessive constipation|
|Loss of Bowel Control|
|Loss of Bladder Control|
|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|
|Extreme physical sensitivity|
|Extreme emotional sensitivity|
|No Recollection of the electrical accident||N/A|
|Personality or Mood Swings|
|Severe menstrual cramps|
|Cognitive problems (lack or loss of reasoning skills)|
|Weight gain and/or loss|
|Ringing in ears|
|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|
|Loss of ability to talk|
|Loss of ability to talk|
|Insomnia (sleep disorders)|
|Weakness in joints|
|Stiffness in joints|
|Convulsions or seizures|
|Sensitivity to Light|
|Tingling in hands|
|Tingling in arms|
|Tingling in legs|
|Pins and Needles in Hands|
|Chronic pain (generalized)|
|Increasee temper (unexplained)|
|Inability to cope with life in general|
|Dental Problems (Broken teeth or teeth hurt)|
|Feeling of hopelessness|
|Loss of appetite|
|Lack of motivation|
(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)|
|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)|
|Wounds requiring amputation|
|Other Broken bone(s)|
|First Degree Burns||N/A|
|Second Degree Burns||N/A|
|Third Degree Burns||N/A|
|Abnormal CAT scan|
|Organic brain disorder|
|Rotator Cuff Injury|
|Brachial Plexus Injury|
|Chronic Pain Syndrome|
|Other Neurological Disorder(s)|
|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|
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.)
In the text boxes below, please provide any additional information that is pertinent to the question asked above the box.
4. List any other symptoms or diagnoses which arose or continued more than three weeks and less than six months following your injury:
REMEMBER: To enter your survey, you MUST click
the SUBMIT button below.