Medical Assessment Form

Name of person completing the form *

Patient/Claimant name *

Address *

Gender *MaleFemale

Date of birth *

Occupation (including details of any change since the date of accident) *

Currently at work? *YesNo

Date last worked *

Right or left hand dominant? *RightLeft

Height (cm) *

Weight (kg) *

BMI (and details of any change since accident) *

Date of accident/injury *

Years since date of accident *

Months since date of accident *

Brief accident details *

Brief details of injury/injuries sustained *(Include steps taken immediately after accident and in subsequent few days)

Date first treatment sought *

From who was it received? *

Were you hospitalised? *YesNo

If hospitalised where? *

Duration of inpatient stay?

Total length of absence from work (start date and end date)

If absence is ongoing is it due to the accident?

Are you in other work? *YesNo

Number of GP visits approximately *

Number of specialist/consultant visits *

Identity of specialist/consultant(s), if known

Treatment and Investigations completed to date (related to this accident/injury)

X/Rays or MRIs *

Injections *

Surgery *

Number of physiotherapy sessions, if any

Any other treatments undertaken

Effects on work

Effects on normal activities of daily living

Effects on recreation & sports activities

Pain at night and effect on sleep

Any other relevant information