Questionnaire About YouHealthIncident PainTreatment & ImpactWorkConsent About You Forename Surname Date of Birth Date of Incident Age now Age at incident Handedness [radio* handedness use_label_element default:1 "Right" "Left" "Ambidextrous"] Marital status (before) SinglePartnerMarriedDivorcedSeparatedWidowed Marital status (now) SinglePartnerMarriedDivorcedSeparatedWidowed Dependent children? YesNo If yes, how many? —Please choose an option—1234>5 Ages Household AlonePartnerChildrenParentsOther Smoker? YesNo If yes, per day Alcohol? YesNo If yes, drinks per week Recreational drugs? YesNo Previous medico-legal claims? YesNo Court appearances? YesNo Next Your Health Before the Incident Tick illnesses you have had. If yes, did they restrict work or usual activities more than one week. High blood pressure YesNo Restricted >1 week? YesNo Diabetes YesNo Restricted >1 week? YesNo Neck pain YesNo Restricted >1 week? YesNo Low back pain YesNo Restricted >1 week? YesNo Anxiety YesNo Restricted >1 week? YesNo Depression YesNo Restricted >1 week? YesNo Other conditions Pain medications BEFORE the incident Name Strength Frequency Helped? YesNo Name Strength Frequency Helped? YesNo Estimated relief —Please choose an option—0%10%30%40%50%60%70%80%90%100%N/A Other medications BEFORE the incident Name Strength Frequency Helped? YesNo Allergies? YesNo Family history Back Next The Accident / Incident Motor vehicle accidentWork relatedClinical accident during medical treatmentOther Describe the incident Present symptoms List up to five pain sites. Site Character Level MildModerateSevere Radiation Timing Aggravating Relieving Duration Change BetterNot changedWorse Back Next Pain scales (last week) Worst Average Best Mood in the last two weeks Little interest in doing things Not at allSeveral daysMore than half the daysNearly every day Feeling down, depressed or hopeless Not at allSeveral daysMore than half the daysNearly every day Health anxiety and attention Symptoms after reading about illness? NoRarelySometimesOftenMost of the time Worry when noticing a body sensation? NoRarelySometimesOftenMost of the time Hard to think of something else? NoRarelySometimesOftenMost of the time Your view What do you think is causing your present symptoms? Do you think you will get back to pre-accident you? [radio* recover_expect use_label_element "Yes" "No"] If YES, what will you need? If NO, why not? What would you like from the legal process? An apologyChange in practiceMoney to restore functionOther Back Next Treatment after the incident Treatment Now Past Helped Sessions Pain medications NowPastHelped Physiotherapy NowPastHelped Injections NowPastHelped Surgery NowPastHelped Acupuncture NowPastHelped Osteopathy/Chiro NowPastHelped Pain team/programmes NowPastHelped Counselling/CBT NowPastHelped Planned future treatment? Activities and function Walk – before: YesNo After impact: NoneMildModerateSevere Need help? YesNo Tolerances Sit 153060120other Stand 153060120other Walk 153060120other Drive 153060120other Passenger 153060120other Good and bad days Do you get good and bad days? YesNo Good days per week Bad days per week Today is a Good dayBad day On a good day I can On a bad day I cannot Home and care Moved since injury? YesNo Date Accommodation type FlatHouseHostelHotelOther Floors 123>4 Stairs or lift to front door? StairsLiftLevel Changes made (e.g. rails) Domestic tasks and care Make tea or coffee YesNo Need help NoneSometimesAll the time Travel and hobbies Can travel by CarBusTaxiPlaneTrain Travel changed since accident? YesNo Do you drive? YesNo Holiday since? YesNo Hobbies (and changes) Social life changes Back Next Work and Benefits Before the accident Employed full-timeEmployed part-timeSelf employedUnemployedFull-time studentRetiredFull-time homemaker/carer Job title Nature of work ClericalManualCombination Hours per week 10203040506070>70 Time in job Extended sickness >2 weeks pre-incident? YesNo Career breaks? YesNo Job satisfaction before (1-10) After the accident Working now? YesNo Time off due to accident? YesNo Stopped work (date) Returned to work (date) Current job status Same jobDifferent jobDo not work Hours per week now 10203040506070>70 Work impairment (0-10) Chance working in 6 months (1-10) Job satisfaction now (1-10) Days missed due to pain (past 12 months) 01-23-78-1415-301-2 months3-6 months6-12 monthsover 1 yearNot working Statutory Sick Pay? YesNo Benefits Job Seeker's AllowanceIncome SupportIncapacity BenefitESADLAPIP Applied for disability allowance before? YesNo Before or after incident? BeforeAfter Back Next Consent and Contact Consultations may be recorded; photos or videos may be taken; reports may be emailed for convenience. Recording AgreeDisagree Photos or videos AgreeDisagree Emailing report AgreeDisagree Mobile Email [acceptance* privacy-consent] I confirm the information is true to the best of my knowledge and I consent to processing for medico-legal assessment. This form is not monitored for emergencies. If you need urgent help, call 999.[/acceptance] Back
