<p> ACCIDENT QUESTIONNAIRE</p><p>PLEASE DO THIS ONLINE AT WWW.WEBQUESTIONNAIRE.CO.UK THE SECURITY CODE IS IN YOUR APPOINTMENT LETTER</p><p>If you do not do it online please fill in all of this </p><p>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</p><p>Page 1 of 2 Proof of Identity:  Driving licence  Passport  Birth certificate Work ID  Bank card  Other………………… Accompanied by: Dominant hand:  Right  Left </p><p>PERSONAL DETAILS: Title : Mr / Mrs / Miss / Ms Approximate Weight :</p><p>Full Name : Approximate Height :</p><p>Present Address: Date Of Birth : Age :</p><p>Post Code: ANY SIGNIFICANT MEDICAL PROBLEM / SIMILAR PAIN / ANY PREVIOUS ACCIDENT BEFORE THIS ACCIDENT: </p><p>Any previous accident, musculoskeletal or psychological symptoms ? ______</p><p>How long ago ______Recovered after ______days/ months/ years, Symptoms worsened in this accident?  Yes  No </p><p>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) ______</p><p>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</p><p>Type of impact?  Hit by  crashed into Looking towards  Ahead  Left  Right  Rear  Reading</p><p>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</p><p>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: </p><p>Injuries Sustained After the Accident? When started? How are they Now?</p><p> o mild o moderate o severe o Resolved o mild o moderate o severe</p><p> o mild o moderate o severe o Resolved o mild o moderate o severe</p><p> o mild o moderate o severe o Resolved o mild o moderate o severe</p><p>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</p>