Personal Injury Medical Questionnaire Form

Personal Injury Medical Examination Questionnaire

Claim Details

1. Personal Details

DD slash MM slash YYYY
Address Line 6 (Country)(Required)

2. Incident Details

DD slash MM slash YYYY
2.b. Approximate Time of Incident(Required)
2.c. What was the Weather Like at the Time of Accident? (Tick as many as apply)(Required)
2.d. What type of vehicle were you in at the time of the accident?(Required)
2.e. What type of vehicle was the third party using?(Required)
2.f. Were you the driver or passenger in the vehicle?(Required)
2.g. If your were the driver, were you alone or had any passenger(s)?(Required)
2.h. Were you wearing a seat belt at the time of accident? I(Required)
2.i. Was a head restraint fitted to your car seat?(Required)
2.j. Where were you hit by a third party vehicle(s)?(Required)
2.k. Total number of vehicles involved(Required)
2.l. What was the total number if impacts to your vehicle?(Required)
2.m. Was your vehicle stationary or moving at the time of impact?(Required)
2.n. What was your movement during the impact?(Required)
2.p. Did you drive your vehicle after the accident?(Required)
2.q. Was your vehicle driveable after the accident?(Required)
2.r. What happened to your vehicle?(Required)

3. Injuries Sustained or Symptoms - Please describe all physical injuries sustained or symptoms you suffered since accident. Please write N/A if not applicable.

3.a. Injury No.1 Neck Injury following the accident(Required)
3.b. Associated symptoms with Injury No.1. Did you sustain any headache following the accident?(Required)
3.c. Associated symptoms with Injury No.1. Did you suffer from any other pain, paraesthesia or neurological symptoms following the accident? (Tick as many boxes as apply)(Required)
3.d. Injury No.2 Back Injury following the accident(Required)
3.e. Associated symptoms with Injury No.2. Did you suffer from any other pain, paraesthesia or neurological symptoms following the accident? (Tick as many boxes as apply)(Required)
3.f. Associated symptoms with Injury No.2. Did you suffer from any other pain, paraesthesia or neurological symptoms following the accident? (Tick as many boxes as apply)(Required)
3.g. Injury No.3 Cranium Injury following the accident(Required)
3.i. Injury No.4 Chest Injury following the accident(Required)
3.k. Injury No.5. Upper Limb Injury following the accident(Required)
3.m. Did you sustain any Psychological Injury?(Required)
3.n. What type of Psychological Injury did you sustain? (Tick as many as apply)(Required)

4. Treatment Recieved

4.a. Please describe any examination after the accident.(Required)
4.c. Were you investigated for your injuries? (e.g. X-rays etc.)(Required)
4.e. Have you recieved any treatment so far? (Tick as many as apply)(Required)

5. Progression of Symptoms - In relation to Section 3, how have you felt since the accident?

Injury No.1 (Neck)
Injury No.2 (Back)
Injury No.3 (Cranium)
Injury No.4 (Chest)
Injury No.5 (Other)

6. Past Medical History (Before your accident)

6.a. Please select any conditions you had in the past (Tick as many as apply)(Required)
6.d. Are you Right-hand or Left-hand Dominant?(Required)
6.e. Were you involved in any previous Road Traffic Accidents?(Required)
6.g. Have you made any claims in the past following personal injury or disability?(Required)
6.h. Did you suffer or had any previous similar injuries or problems as sustained during the accident?(Required)

7. Effects of Accident/Injuries

7.a. Did you have any mental health problems after this accident or injuries sustained?(Required)
7.c. Have you resumed your driving now?(Required)
7.d. Do you feel progressively better on the roads so far?(Required)
7.f. What was your status on work/job at the time of accident?(Required)
7.h. Is your job manually or physically demanding?(Required)
7.i. Does your job involve considerable travelling?(Required)
7.j. Do you live alone or with others?(Required)
7.l. Did your household activities suffer as a result of the accident?(Required)
7.m. What was the approximate period of struggle as a result of this accident?(Required)
7.p. Were you physically dependent upon anyone since this accident?(Required)
7.q. Did you require any outside help for your daily domestic commitments?(Required)
7.r. Has sleeping been a problem since your accident?(Required)
7.t. What hobbies or sports activities do you have? (Please tick all those that apply)(Required)

8. Present State

8.a. At the time of completing this form, how do you feel now since the accident?(Required)
8.b. In relation to section 3 and Injury No.1 - Please state the percentage of improvement of your symptoms. 0% means no improvement, 100% means fully recovered.(Required)
8.c. In relation to section 3 and Injury No.2 - Please state the percentage of improvement of your symptoms. 0% means no improvement, 100% means fully recovered.(Required)
8.d. In relation to section 3 and Injury No.3 - Please state the percentage of improvement of your symptoms. 0% means no improvement, 100% means fully recovered.(Required)
8.e. In relation to section 3 and Injury No.4 - Please state the percentage of improvement of your symptoms. 0% means no improvement, 100% means fully recovered.(Required)
8.f. In relation to section 3 and Injury No.5 - Please state the percentage of improvement of your symptoms. 0% means no improvement, 100% means fully recovered.(Required)
8.g. Are you still having problems carrying out daily activities?(Required)
Consent: I consent for my practitioner to collect, store and utilise this personal information for the purposes of providing services to me in accordance with the relevant privacy legislation and any other legal requirements that may apply.(Required)
This field is for validation purposes and should be left unchanged.