Medical Report Proforma

ACCIDENT QUESTIONNAIRE

PLEASE DO THIS ONLINE AT WWW.WEBQUESTIONNAIRE.CO.UK THE SECURITY CODE IS IN YOUR APPOINTMENT LETTER

If you do not do it online please fill in all of this

Linked Cases? Do you have a friend relative who was also in the accident? If you have not been booked together please call me to arrange

of 2 Proof of Identity:  Driving licence  Passport  Birth certificate Work ID  Bank card  Other………………… Accompanied by: Dominant hand:  Right  Left

PERSONAL DETAILS: Title : Mr / Mrs / Miss / Ms Approximate Weight :

Full Name : Approximate Height :

Present Address: Date Of Birth : Age :

Post Code: ANY SIGNIFICANT MEDICAL PROBLEM / SIMILAR PAIN / ANY PREVIOUS ACCIDENT BEFORE THIS ACCIDENT:

Any previous accident, musculoskeletal or psychological symptoms ? ______

How long ago ______Recovered after ______days/ months/ years, Symptoms worsened in this accident?  Yes  No

DETAIL OF THE ACCIDENT (INCIDENCE): Date of accident: Type Of Accident (Please select one) :  Pedestrian  Road Traffic Accident  Trips Or Fall  Injury at Work Time of accident:  Morning  Afternoon  Evening  Night  Others Your Vehicle (e.g. car, van, bus, 4x4, truck etc.)______Other Vehicle(s) (Collided with) (e.g. car) ______

Position:  driving  front seat passenger  back seat passenger Location:  Roundabout  Road o Motorway  Junction Traffic queue  Traffic light Movement:  Stationary  Moving Road Surface?  Dry  Wet Visibility  Good  Poor

Type of impact?  Hit by  crashed into Looking towards  Ahead  Left  Right  Rear  Reading

Direction of impact?  Front/Head-on  Passenger’s side  Driver’s side  Rear Speed of the impact?  High (motorway)  Medium (city road)  Low (late braking) Damage to the Vehicle?  Written off  Extensive damage  Moderate  Slight damage

Wearing Seatbelts?  Yes  No Got out of vehicle  Yes unaided?  No Vehicle fitted with headrests?  Yes  No  Don’t know Airbag Fitted and deployed?  Yes  Fitted but not deployed  Not fitted Please describe the incident in brief:

Injuries Sustained After the Accident? When started? How are they Now?

o mild o moderate o severe o Resolved o mild o moderate o severe

BRIEF POST ACCIDENT & TREATMENT DETAIL: Were you attended at the scene by?  Paramedics  First- Aider  Fireman  Police  Other ………………… None Immediately after the accident where did you go to? ______How did you travel? ______Attended Hospital?  Yes  No after………………?days  Advice______ Treatment______Attended GP?  Yes  No after………………?days  Advice______ Treatment______Had X-ray?  Yes  No if yes which part ……………….. If yes the outcome:Page 2 of 2  no bony injury(normal)  bony injury Had Physiotherapy?  Yes  No and had ………..sessions