Pre Interview Medical Questionnaire

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Your Details

So, of currently

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth *

Age

Occupation

Hours worked per week

Current Occupation

Marital status

Number of dependent children

Left or right handed

The Accident

Date and time of the accident

Date

Time

Describe the accident

What were your injuries?

Did an ambulance attend

Did you go to hospital

Which hospital did you attend?

What treatment was given

Pre-Accident

How were you before the accident in terms of

Please indicate if you were independent, required assistance etc.

Self-care

Mobility

Any relevant health issues?

GP

Have you seen your GP since your accident

If So, for what did you need to see your GP for?

Please list the medications you currently take

Physiotherapy

Did you have physiotherapy?

If so, for how long?

Any other type of therapy?

i.e. hydrotherapy, occupational therapy, etc.

Current symptoms

Can you describe your symptoms in terms of:

Areas involved *

Type of pain

i.e. pins and needles, throbbing, aching, etc.

Provoking symptoms

How is the pain relieved

Do you have weakness in any part of your body? If so, where?

What can you no longer do that you used to do before?

Is your sleep affected? Do you wake up at night due to symptoms?

Psychological symptoms

Tearfulness *

Anxiety *

Depression *

Flashbacks *

Nightmares *

Panic attacks *

Mood swings *

Irritable *

Previous Conditions

Have you been injured in these areas before? *

Even if not injured, have you had any previous symptoms in these areas? *

Have you had a significant time off work with illness before

please describe

What other medical conditions do you have

Work

Is this the same job you had at the time of the accident?

If not describe

How much time did you have off work

Did you return to work fulltime/ phased return

Did your injury affect your ability to work

Did you need help from colleagues at work

Have you returned to driving *

If you drive

Homelife

Did you require help with the following activities (if yes, how long for)?

Bathing

Showering

Dressing

Hoovering

Washing up

Cooking / Meal prep

Laundry

Shopping

Stairs

Gardening

Sleep

Do you live alone?

Who helps you?

Aids

Do you require any aids/adaptations to:

Work?

Please describe

Home life?

Please describe

Mobility?

Please describe

Hobbies and Social life

What are your hobbies?

How long did you avoid them? Have you returned to your hobbies?

Why did you avoid them?

Has your social life been affected by the accident?

In what other ways have you been affected by the accident?

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Print Name *

Full name of parent/guardian (if consenting for a minor a person with a decision-making disability)

Signature *

Clear Signature

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