If you where you in a vehicle at the time of the accident, please complete 1a. below. If you where not in a vehicle, please go to 1b on page 3.
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1 1 Pre-Medical Questionnaire Very Important: Please take time to carefully complete this form before your medical. The information you include in this form will be incorporated your medical report to your solicitor and will therefore affect the value of your claim. About You Your Name Daytime contact no Date of Birth: Right or Left Handed: If you where you in a vehicle at the time of the accident, please complete 1a. below. If you where not in a vehicle, please go to 1b on page 3. 1a.The Accident (In a Vehicle) This part of the form is for people who were in a vehicle at the time of the accident. If that doesn t apply to you, please describe your accident on the back of this page. Date of Accident: Approx Time of Accident: Your Vehicle: What kind of vehicle were you in? Your Position: Driver, front or rear seat passenger? Seat Belt: Were you wearing a seatbelt? Head Rest: Was a headrest fitted? Air Bag: Was there one? Did it deploy? Your Vehicle s Movement: Moving, stationary or turning? Your Vehicle s Location: Roundabout, traffic lights etc.
2 2 The impact Briefly describe how the accident happened, the speed and force of it, and which part of your vehicle was hit. Expecting the accident: Were you expecting to be hit? Did you brace for impact? Damage to Your Vehicle: How badly damaged was it? Thrown at Impact: How were you thrown at impact? Get Out of Vehicle: Did you need any help to get out?
3 3 1b.The Accident (non-vehicle) Date of Accident: Approx Time of Accident: Please describe how the accident occurred below:-
4 4 2a. Initial Injuries and Symptoms Please describe the injuries or symptoms you noticed at the time of the accident. Include both physical and any psychological symptoms you experienced. If you need more space, you can continue this section at the end of this form. Injury or Symptom: Briefly describe what you felt. Initial Severity: How bad was it at first? Mild, Moderate, Severe Current Status: How bad is it now? Mild, Moderate, Severe If it has resolved, how long after the accident did it resolve? Example: Neck Pain Moderate Cleared up after 3 months.
5 5 2b. Later Symptoms Please describe any symptoms that came on some time after the accident. Symptom: Briefly describe what you felt. Delay: How long after the accident did it start? Initial Severity: How bad was it at first? Mild, Moderate, Severe Current Status: How bad is it now? Mild, Moderate, Severe If it has resolved, how long did it take to resolve? Example: Back Pain 3 days Moderate Still stiff and sore.
6 6 3a. Initial Treatment What treatment did you receive on the day of the accident? Treatment at the Scene: Did you need any? Who treated you? e.g. paramedic, passer-by What was the treatment? e.g. dressings, painkillers Travel from the Scene: Where did you go next? e.g. home, work, Casualty How did you travel there? e.g. drove, got a lift, by ambulance Other Treatment on the day of the accident: Did you have any? Where did you have it? e.g. Casualty, GP, work, home What was the treatment? e.g. dressings, painkillers Did you have any tests? e.g. x-ray of neck What were the results? e.g. normal, fracture 3b. Later Treatment What other treatment have you received since the accident? Treatment: What treatment have you had? How many visits or sessions? e.g. GP, physiotherapy Example: Attended GP 3 times Timing: How long after the accident did you start the treatment? 3 days, 2 weeks, and 4 weeks Outcome: How successful has it been? e.g. physio improved neck pain e.g. GP gave sick note and painkillers Got sick note, painkillers and physio referral.
7 7 4.a Effect on Work How has the accident affected your work? If you have more than one job, please give details on the back of this page. What is your job? e.g. taxi driver Normal hours per week: e.g. 40 hours How much time off? e.g. none, 2 weeks, still off? Light Duties? For how long? Duties still light? Reduced Hours? For how long? Hours still reduced? Lost Job? Why? What happened? Changed Job? Why? What do you do now? 4b. Effect on Travel Have you had any problems as a driver or a passenger? As a Driver: Any pain or discomfort? How severe has it been? How long has it lasted? Any anxiety? How severe has it been? How long has it lasted? As a Passenger: Any pain or discomfort? How severe has it been? How long has it lasted? Any anxiety? How severe has it been? How long has it lasted?
8 8 4c. Home Situation Who lives with you at home? Adults: e.g. partner e.g. parents Children: How many? What are their ages? 4d. Effect on Home Life How has the accident affected your home life? If there have been any problems, please list them below. Activity Problem: Briefly describe the problem. e.g. housework, shopping, sport. e.g. missed out on holiday (include destination) or special event. Current Status: How bad was it to start with? How bad is it now? If it has resolved, how long did it take to resolve? Example: shopping Could not do shopping because of shoulder pain. Husband had to carry the bags. It settled after 3 weeks, but I still have problems with heavy items. Personal care (washing/dressing) Housework Shopping
9 9 4d. Effect on Leisure/sport activites Activity Example: Swimming frequency of activity before accident Normally went swimming three times per week Effect on activity Had to stop swimming completely for 2 months. Now swimming restricted to once a week 4e. Effect on sleep Example: I am normally a good sleeper My sleep was severely disturbed for 3 weeks Other Information or Comments Please use this space to add any other information or comments you wish:
10 10 Past Medical History Have you had any previous accidents, injuries or health problems? Please list them here, including when they occurred, what treatment was needed, and whether they still affect you now. If you need more space, please continue over the page. Previous Accidents? When did it happen? What injuries did you have? Did you make a full recovery? How long did your recovery take?
11 11 Physical Health? Are you normally in good health? Have you had any serious illnesses? Have you had neck, back or shoulder problems in the past? Mental Health? Have you had any problems with anxiety or depression? Current Medication? What treatments do you take? Final Declaration Thank you very much for completing this questionnaire. The information will be used as part of the medical report that the doctor writes about you, so it is important that it is as detailed and accurate as possible. I confirm that the information given in this questionnaire is a true and accurate description of the circumstances and injuries of my accident Name: Dated
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