Medico-legal questionnaire

Dr Towlerton questionnaire

Questionnaire for reports

Please take some time to answer the following questions. This helps us understand how you are functioning now and supports preparation of the report.

Some questions may feel similar or seem unusual, but they each help build a fuller picture. Please answer as accurately and honestly as you can.

If anything is unclear, leave your best answer and it can be clarified later if needed.

Your progress saves as you go. If you want to leave and return later, please copy and keep the private link that appears once your draft starts.

This form is long. Work through one section at a time. Required questions are marked with an asterisk.

Information submitted through this questionnaire is stored securely in the website database for clinical and medico-legal administration. Records should be retained and reviewed in line with the practice's own privacy, retention and backup policies.

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Step 1 of 10

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Step 1

About You

Basic details and background information.

Forename *

Surname *

Date of birth *

Age *

Age at the time of the incident *

Date of incident / accident *

Before and after comparison

BeforeHas this changed?Now

Handedness

Right Left Ambidextrous

Yes No

Right Left Ambidextrous

Marital status

Single Partner Married Divorced Separated Widowed

Yes No

Single Partner Married Divorced Separated Widowed

Dependent children

Yes No

If you have dependent children, how many are there and what are their ages?

Who lives at home with you?

Alone Partner Children Parents Other

Lifestyle before and after the accident

This groups together smoking, alcohol and recreational drug use so it is easier to complete online.

BeforeHas this changed?Now

Smoking or tobacco use

Yes No

Alcohol use

Yes No

Recreational or street drug use

Yes No

If you currently smoke or use tobacco, roughly how many per day?

If you currently drink alcohol, roughly how many drinks per week?

Have you made any previous medicolegal claims?

Yes No

Have you had any court appearances?

Yes No

Step 2

Health Before the Accident

Relevant health history before the accident or incident.

Before the accident, had you ever had any of the following conditions?

ConditionEver had this?Restricted work/activities for more than 1 week?

High blood pressure

Yes No

Diabetes

Yes No

Heart disease

Yes No

Bowel disease

Yes No

Neurological problems

Yes No

Joint problems

Yes No

Anxiety

Yes No

Depression

Yes No

Neck pain

Yes No

Low back pain

Yes No

Widespread pain

Yes No

Fibromyalgia

Yes No

Irritable bowel syndrome

Yes No

Chronic fatigue

Yes No

Myalgic encephalomyelitis

Yes No

Migraine

Yes No

Any other relevant health conditions before the accident?

Before the accident, were you taking pain medication?

Yes No

Pain medication before the accident

NameStrengthFrequencyDoes it help?

Yes No

If so, how much did that help overall?

Before the accident, were you taking any other medication?

Yes No

Other medication before the accident

NameStrengthFrequencyDoes it help?

Yes No

Do you have any allergies, either past or present?

Yes No

If yes, please give details

Is there any relevant family history of illness?

Step 3

Incident, Symptoms and Pain

Details of the incident and your current symptoms.

Incident

Type of incident

Motor vehicle accident

Yes No

Work related

Yes No

Clinical incident during medical treatment

Yes No

Other

Yes No

Please describe what happened *

Please describe where you feel pain or symptoms now

Pain description

Use this to describe up to 5 pain areas if needed.

Pain 1Pain 2Pain 3Pain 4Pain 5

Site

Character

Pain level

Radiation

Time pattern

Aggravating factors

Relieving factors

Duration

Trend

Scoring

Pain scores

Pain at its worst in the last week

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Average pain in the last week

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Pain at its best in the last week

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Screening

Mood and symptom awareness

Over the last 2 weeks, how often have you had little interest in doing things?

Over the last 2 weeks, how often have you felt down, depressed or hopeless?

When you read or hear about an illness, do you notice similar symptoms in yourself?

When you notice a sensation in your body, do you worry about it?

When you feel a sensation in your body, is it hard to think about anything else?

What do you think is causing your current symptoms?

Do you think you will get back to how you were before the accident?

Yes No

If yes, what do you think will help you get there?

If no, why not?

What would you like from the legal process?

An apology Change in practice Money to restore my function Other

Step 4

Current Medication and Treatment

Your current pain medication and any treatment you have had since the incident.

What pain medication are you taking now?

NameStrengthFrequencyDoes it help?

Yes No

How much does your current pain medication help overall?

Any pain medication tried since the incident that you are no longer taking?

NameStrengthFrequencyDoes it help?

Yes No

Treatment since the incident

TreatmentNowPastHelpedSessions

Pain medication

Physiotherapy

Injections

Surgery

TENS

Acupuncture

Osteopathy

Chiropractic

Alternative therapies

Non-prescribed medication

Pain team

Pain management programme

Counselling

Other

Is any further treatment planned?

Step 5

Daily Function and Activity

How the injury or incident affects daily life.

Impact on daily activities

ActivityCould do beforeImpact nowNeed help

Walk

Yes No

Stand

Yes No

Sit

Yes No

Reach

Yes No

Bend

Yes No

Go upstairs

Yes No

Go downstairs

Yes No

Domestic duties

Yes No

Self care

Yes No

Showering

Yes No

Dressing

Yes No

Getting ready for bed

Yes No

Cleaning and tidying

Yes No

Meal preparation

Yes No

Laundry

Yes No

Shopping

Yes No

Fetching

Yes No

Carrying

Yes No

Running errands

Yes No

Writing

Yes No

Thinking

Yes No

Travel

Yes No

Driving

Yes No

Leisure activity

Yes No

Dealing with litigation

Yes No

Any other activities affected?

How much does pain limit the following?

ActivityNoA littleA lot

Vigorous activities

Moderate activities

Lifting or carrying groceries

Climbing several flights of stairs

Climbing one flight of stairs

Bending, kneeling or stooping

Walking more than a mile

Concentrating

Writing or typing

How long can you usually do the following?

Activity153060120Other

Sit

15 30 60 120

Stand

15 30 60 120

Walk

15 30 60 120

Drive

15 30 60 120

Travel as a passenger

15 30 60 120

Do you have good days and bad days?

Yes No

If yes, roughly how many good days per week?

Roughly how many bad days per week?

How would you describe today?

A good day A bad day

What can you do on a good day?

What can you not do on a bad day?

Are there activities you can no longer do, or now do differently?

How has your day-to-day routine changed since the accident?

Step 6

Accommodation, Care and Daily Living

Your current living arrangements, domestic activities and care needs.

Have you moved since the accident or injury?

Yes No

If yes, when?

What type of accommodation do you live in now?

How many floors does it have?

Are there stairs or a lift to the front door?

Yes No

Have there been any changes to your home because of the accident or injury?

Has the way you manage washing, dressing or personal care changed?

Yes No

If yes, please describe

Have you had to change what you do around the home?

Yes No

If yes, what has changed?

Domestic tasks

ActivityCan you do this?Do you need help?

Make a drink

Yes No

Sometimes All the time

Cook a meal

Yes No

Sometimes All the time

Hoover

Yes No

Sometimes All the time

Clean and tidy

Yes No

Sometimes All the time

Use a dishwasher

Yes No

Sometimes All the time

Do the laundry

Yes No

Sometimes All the time

Change a bed

Yes No

Sometimes All the time

Put out the bins

Yes No

Sometimes All the time

Do the shopping

Yes No

Sometimes All the time

Do you need any additional care because of the accident?

Yes No

If yes, who provides that care?

Family Friend Paid carers Cleaners Other

How many hours of additional help do you receive on average per week?

Step 7

Travel, Hobbies and Social Life

Changes to travel, holidays, hobbies and social life.

Which of these can you travel by?

Car Bus Taxi Plane Train

Has your ability to travel changed since the accident?

Yes No

Do you drive?

Yes No

Have you been on holiday since the accident?

Yes No

Do you have any hobbies or regular leisure interests?

Yes No

If yes, please list them

Have those hobbies changed since the incident?

Has your social life changed?

Yes No

If yes, how has it changed?

Do you use social media?

Yes No

If yes, which platforms?

Facebook Instagram Twitter/X

Step 8

Work and Benefits

Your work situation before and after the accident.

What was your work situation before the accident?

Job title

Nature of work

Hours worked per week before the accident

How long had you been doing that job?

Had you taken any extended time off before the incident?

Yes No

Had you had any career breaks before the incident?

Yes No

How satisfied were you with your job before the accident?

12345678910

Are you working now?

Yes No

Did you take time off because of the accident?

Yes No

If yes, when did you stop work?

If applicable, when did you return to work?

What is your current work situation?

If working, how many hours per week do you work now?

How much does your condition affect your ability to work?

012345678910

What do you think the chances are that you will be working in 6 months?

12345678910

How satisfied are you with your job now?

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How many days of work have you missed because of pain during the last 12 months?

Are you currently receiving Statutory Sick Pay?

Yes No

Are you currently receiving Job Seeker's Allowance, Income Support or Incapacity Benefit?

Yes No

Are you receiving ESA?

Yes No

Are you receiving DLA?

Yes No

Are you receiving PIP?

Yes No

Have you ever applied for a benefit or disability allowance?

Yes No

If yes, when?

Was that before or after this incident?

Step 9

Scored Questionnaires

Standardised pain and symptom questionnaires.

Pain interference

General activity

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Mood

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Walking ability

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Normal work

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Relations with other people

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Sleep

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Enjoyment of life

12345678910N/A

How strong is your pain right now?

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How strong was the strongest pain during the last 4 weeks?

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How strong was the pain on average during the last 4 weeks?

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Which description best matches the course of your pain?

Please describe the main area of pain

Does your pain radiate to other parts of the body?

Yes No

If yes, please describe where it travels

Pain sensations

Burning sensation