Step 1 of 3 33% Do you have any Covid symptoms Yes No GDPR Consent I give my consent for my personal data and medical files to be used in this questionnaire. HiddenAdministrator Email REF Claimant First Name* Claimant Last Name:* Address*Gender* Male Female Date of Birth* DD slash MM slash YYYY Occupation*(including details of any change since the date of accident)Currently at work?* Yes No Right or left hand dominant?* Right Left Height* Weight* Date of accident* DD slash MM slash YYYY Appointment/Examination Date* DD slash MM slash YYYY Total time elapsed since date of accident(date of accident to examination date Years/Months) Brief Accident DetailsBrief Details of Injury/Injuries Sustained (Include history of condition immediately after accident and in subsequent few days)Date first treatment sought DD slash MM slash YYYY From who was it received? Was claimant hospitalised? Yes No If hospitalised where? Duration of inpatient stay? Total length of absence from work - From DD slash MM slash YYYY Total length of absence from work - To DD slash MM slash YYYY If absence is ongoing is it due to the accident? Yes No Was/is the claimant’s absence period reasonable? Yes No Number of GP visits Number of Specialist/ Consultant visits Identity of Specialist/ Consultant(s), if known Treatment and Investigations to date1. XRays/ MRI scansType of scan you had. Where did you have it done? IMPORTANT: Please bring your scans with you on the day of your appointment.2. SurgeryWhat surgery did you have and on what part of your body?3.PhysiotherapyHow many session did you have. Was your physiotherapy with a chartered physiotherapist?Please check this box if you had previous injury/ claim as a result of an accident? Please detail previous injury/claimDo you have any other medical conditions* Yes No Please detail your condition Please Submit the form here so we can progress to the next step. Relevant Medical History (including previous and subsequent accidents and clarification on any interaction of injuries)Relevant history? Yes No Aggravation of pre-existing condition? Yes No If yes please give nature of pre-existing condition Was pre-existing condition active/symptomatic before the accident? Present Complaints(Include effects on lifestyle/recreational and domestic/personal activities)Visual Analogue Scale (VAS) for pain score Clinical Findings on Examination(Range of movement(s))Please Complete This Section Only if a Claimant has suffered Neck Pain or Whiplash Associated Disorder (WAD)Did this patient have a neck injury?* Yes No Findings as at time of examinationAssessment of cervical range of motion Normal Abnormal Palpation for consistent tenderness Present Absent Neurological signs Present Absent Following Assessment claimants should be classified according to the Quebec Task Force (QTF) Classification of GradesIndicate the Whiplash Associated Disorder (WAD) Grade WAD 0 - (No neck pain, stiffness or any physical signs are noticed) WAD I - (Complaints of neck pain, stiffness/but no physical signs) WAD II - (Neck complaints & decreased range of motion & local tenderness in the neck) WAD III - (Neck complaints & neurological signs) WAD IV - (Neck complaints & fracture, dislocation or injury to the spinal cord) If the claimant’s WAD Grade has changed during the course of their recovery, please comment on these changes:Neck Disability Index (NDI) score (%) Clinical Description of effects of Claimant’s Illness/Accident/Disablement – practitioners should indicate the degree, if any, to which the claimant’s condition is currently affecting his/her ability in the following;Mental Health Normal Mild Moderate Severe Profound Learning/Intelligence Normal Mild Moderate Severe Profound Consciousness/Seizure Normal Mild Moderate Severe Profound Balance/Co-ordination Normal Mild Moderate Severe Profound Vision Normal Mild Moderate Severe Profound Hearing Normal Mild Moderate Severe Profound Speech Normal Mild Moderate Severe Profound Continence Normal Mild Moderate Severe Profound Reaching Normal Mild Moderate Severe Profound Manual Dexterity Normal Mild Moderate Severe Profound Carrying/Lifting Normal Mild Moderate Severe Profound Bending/Stooping Normal Mild Moderate Severe Profound Sitting Normal Mild Moderate Severe Profound Standing Normal Mild Moderate Severe Profound Climbing Stairs Normal Mild Moderate Severe Profound Walking Normal Mild Moderate Severe Profound Opinion/General Comments and Latest PrognosisIndicate the degree to which you feel all of the claimant’s symptoms/disability have been caused by the accident/event which is the subject of this claim; based on assessment of the injury as described by the claimant the accident/events accounts for (tick one box)Degree to which you feel all of the claimant’s symptoms/disability 1. None of the symptoms/disability 2. A small proportion (≤ 25%) of the symptoms/disability 3. A moderate proportion (50%) of the symptoms/disability 4. Most (≥ 75%) of the symptoms/disability 5. All of the symptoms/disability Comment FurtherAre further investigations required? Yes No Details of further investigationsHave all reasonable steps been taken to alleviate symptoms/disability? Yes No If all reasonable steps have not been taken to alleviate symptoms/disability please elaborateIs a full recovery expected? Yes No Are late complications expected? Yes No If a full recovery is not expected please detail the likely effects on lifestyle/workEstimated total time period from the date of accident to full recoveryYears/Months Are further Specialist reports recommended? Yes No If further Specialist reports are recommended please specifyAnticipated Future Treatment Required(Include approximate future treatment costs if applicable)Summary/Additional InformationCompleted By Completion Date DD slash MM slash YYYY Δ
