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This Questionnaire should take 10-15 minutes, and will greatly speed up the examination process. It is designed for the clients that have had road traffic accidents.

Name:  
Were you in employment at the time of the accident? Yes / No, if no, unemployed, retired, student, housewife etc  
What is your present occupation? e.g driver, home-maker, student, retired etc  
If yes, Employment status? e.g full time, part time, casual etc  
Were you in education at the time of accident? Yes / No; If yes, type of education e.g Uni, college, school? was it full time or part time?  
Marital status? e.g married, single, divorced, separated, minor, etc  

Accident details

Pleas write below the type of accident, e.g e.g.Road Traffic accident, Pedestrian, Trips or fall, injury at work  
What vehicle were you in? e.g. car, van, minibus, bus, coach, motorcycle, lorry, taxi, black cab, bicycle, motorcycle, etc  
Other vehicle involved the accident? (third party): car, van, minibus, bus, coach, motorcycle,lorry, taxi, black cab, etc  
Your location during accident? DriverRiderFront seat passengerRear seat passengerPassengerSeatedStoodPedestrianOther,
Speed of the impact? e.g 30 mph or Low/ Moderate / High or unknown  
Direction of impact? FrontDriver's side (Right side)Passenger's side (Left side)RearNo impact but braked violently to avoid impact
Were there subsequent collisions? Yes / No, if yes please describe what happened  
You vehicle fittings: (Please tick as many as appropriate)? Head restraints were fitted
Head restraints were not fitted
Airbags were fitted and deployed
Airbags were fitted but did not deploy
A child seat was fitted
A child seat was not fitted
A booster seat was fitted
Unknow
Not applicable
Were you wearing a seatbelt? YesNoExemptedNot applicable
Your awareness prior to collision? Not aware of the impending accident impactMomentarily aware of the impending accidentAware and prepared for impactNot applicable
Your physical movements on collision, were you? Jolted forwardsJolted forwards and backwardsJolted forwards and backwards several timesJolted forwards and leftJolted forwards and rightJolted backwardsJolted backwards and forwardsJolted backwards and leftJolted backwards and rightJolted sidewaysJolted sideways to the leftJolted sideways to the rightJolted to both sidesJolted upwardsThrown around the vehicle,Thrown to the ground and landed on the left sideThrown to the ground and landed on the right sideThrown to the ground and landed on the backThrown to the ground and landed on the frontCannot remember the movements on collisionOther.....
Get out of Vehicle: After the accident, were you? Able to exit the vehicle without assistanceAble to exit the vehicle with assistanceUnable to exit the vehicleCut free from the vehicleRemained in the vehicleOther
Your movements following accident. After the accident I continued my journeyI was admitted to hospital via A&EI attended A&EI went to the police stationI went to a relative's houseI was given a lift homeI attended the Walk-In CentreI walked homeI went to work and then homeOther

Injury Details

Please list your injuries indicating where appropriate whether left or right sided.

 

Please try to group your symptoms where possible – e.g. bruising to the left leg, left hip and pelvis rather than 3 separate symptoms.

Were there any physical or psychological injuries or symptoms related to the accident? If yes, please describe the FIRST SYMPTOM below, e.g neck pain and stiffness spreading to upper back and right shoulder or fear of travel etc >>>>> FIRST SYMPTOM <<<<< -------------  
When did you first notice the symptom? (FIRST SYMPTOM) e.g immediately, after 2 hours or 3 days etc  
How severe was the pain at its worst? First Symptom) 1 (Minor/Twinges)
2
3
4 (Moderate)
5
6
7 (severe)
8
9
10
How is the pain now? First Symptom) 0 (resolved)
1 (Minor / Twinges)
2
3
4 (Moderate)
5
6
7 (Severe)
8
9
10
If resolved or improved, after how long, e.g resolved after 8 weeks, or improved after 2 weeks from severe to moderate etc  
SECOND SYMPTOM or other symptom: where were you injured?  
When did you first notice the symptom? (SECOND SYMPTOM) e.g immediately, after 2 hours or 3 days etc  
How severe was the pain at its worst?---->>> Second Symptom ---->>> 1 (Minor/Twinges)
2
3
4 (Moderate)
5
6
7 (severe)
8
9
10
How is the pain now? ---->>> second Symptom >>>---- 0 (resolved)
1 (Minor / Twinges)
2
3
4 (Moderate)
5
6
7 (Severe)
8
9
10
If resolved or improved, after how long, e.g resolved after 8 weeks, or improved after 2 weeks from severe to moderate etc  
THIRD SYMPTOM or other symptom: where were you injured?  
When did you first notice the symptom? (THIRD SYMPTOM) e.g immediately, after 2 hours or 3 days etc  
How severe was the pain at its worst? (Third Symptom) 1 (Minor/Twinges)
2
3
4 (Moderate)
5
6
7 (severe)
8
9
10
How is the pain now? ---->>> THIRD SYMPROM <<<---- 0 (resolved)
1 (Minor / Twinges)
2
3
4 (Moderate)
5
6
7 (Severe)
8
9
10
If resolved or improved, after how long, e.g resolved after 8 weeks, or improved after 2 weeks from severe to moderate etc  
Other Symptoms? Please note them here in a similar format to those above  

Were there any psychological symptoms related to the accident? e.g. feeling shocked & shaken, Fear of travel  etc 

FOURTH / OTHER SYMPTOM or other symptom: where were you injured?  
When did you first notice the symptom? e.g immediately, after 2 hours or 3  
How severe was it at its worst? Fourth symptom 1 (Minor)
2
3
4 (Moderate)
5
6
7 (severe)
8
9
10
How is it now? Fourth symptom 0 (resolved)
1 (Minor / Twinges)
2
3
4 (Moderate)
5
6
7 (Severe)
8
9
10
If resolved or improved, after how long, e.g resolved after 8 weeks, or improved after 2 weeks from severe to moderate etc  
Did you go to hospital because of your injuries? e.g A&E, If yes, number of visits?  
Did you go to see your G.P. about your injuries? If yes, please give number of visits  
Have you taken any medication as a result of this accident? If yes, please give the name of the medication and state how long you used it.  
Have you received / about to commence physiotherapy treatment? If yes, please state: (1) start date (2) how many sessions received so far, (3) which part of your body treated (4) date completed.  
Are you currently undergoing or have you at any time received, or are you about to receive, any treatment for psychological symptoms? If yes, please specify treatment  
Have any investigations been undertaken? If yes, please specify e.g e.g. neck X-ray or lower back MRI scan etc  
Previous Medical History: Have you suffered from any previous symptoms or injuries relevant to your current injuries or symptoms? if yes, please specify………..  
Have you suffered from previous accidents? If yes, Please describe: (1) Type of accident? (2) Accident Date? (3)Injury sustained? (4) how long it took you to recover?  
Have you taken time off work / study as a result of the accident? If yes, Time away from work or study?  
Restrictions upon return to work or study? was it restricted in any way? if yes, Duration Restricted: e.g 2 days or weeks or ongoing  
Were there any financial losses incurred?  
If student, Was there any impact on academic progress?  
Accident effects on your lifestyle: were there any effects on your domestic lifestyle? if yes, please describe below e.g Unable to do ironing for 2 weeks and restricted after that for 3 weeks or ongoing  
Accident effects on your lifestyle: were there any effects on your social lifestyle? If yes please describe e,g unable to go to gym for 2 days and subsequently restricted for 2 weeks.  
Did you miss any events or holidays due to the accident? Yes
No
If yes, please give details.  
Your height, e.g. 5.7foot or 170cm  
Your weight (e.g. 10stone or 63kg)  
Dominant hand? RightLeftAmbidextrousUnknown
 


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