Professional Documents
Culture Documents
Pre-Medical Questionnaire
VERY IMPORTANT: Please complete and return by email 48 HOURS BEFORE
attending your medical medicolegals@hotmail.co.uk.
About You
Full Name:
Stewart durkin
Date of Birth:
09/08/1988
right
Nope
Mental Health?
Nope
Current Medication?
Strong ibrophean
13/07/2015
6pm to 7pm
Your Vehicle:
Your Position:
Driver
Seat Belt:
Yes
Head Rest:
Yes
Air Bag:
Not deployed
Moving
The Impact:
Briefly describe how the accident
happened, the speed and force of it,
and which part of your vehicle was
hit.
No I wasnt
Yes
Still drivable luckily
Thrown at Impact:
Side to side
no
Initial Severity:
Current Status:
Moderate
Cleared up after 3
months.
severe
mild
Back pain
severe
moderate
Later Symptoms
Please describe any symptoms that came on some time after the accident.
Symptom:
Delay:
How long
after the
accident
did it
start?
Initial
Severity:
How bad was
it at first?
Mild,
Moderate,
Severe
Current Status:
How bad is it now?
Mild, Moderate, Severe
If it has resolved, how long did it take
to resolve?
3
days
Moderat
Still stiff and sore.
e
Neck pain
24 hours
severe
Back pain
24 hours
severe
instant
moderate
no
Yes/No
no
home
painkillers
no
no
Later Treatment
What other treatment have you received since the accident?
Treatment:
Timing:
Outcome:
Example:
3 days, 2
weeks, and 4
weeks
36 hours
Attended GP 3
times
24 hours
3 months after
Effect on Work
How has the accident affected your work?
If you have more than one job, please give details on the back of this page.
What is your job?
chef
60
e.g. 40 hours
Light Duties?
For how long? Duties still light?
Reduced Hours?
Lost Job?
no
Changed Job?
no
Effect on Travel
Have you had any problems as a driver or a passenger?
As a Driver:
Any pain or discomfort?
Yes/No
How severe has it been?
How long has it lasted?
Any anxiety?
Yes
Yes/No
How severe has it been?
How long has it lasted?
As a Passenger:
Any pain or discomfort?
Yes
Yes/No
How severe has it been?
How long has it lasted?
Moderate
Its lasted a while
Yes/No
How severe has it been?
How long has it lasted?
Partner
e.g. partner
e.g. parents
Children:
How many?
What are their ages?
1
And age of 2
Current Status:
shopping because of
shoulder pain. Husband had
to carry the bags.
Couldnt do housework was on house rest I was on sofa for a while. 2 weeks resting
but couldnt afford to take any more time
off. Its mild.
Final Declaration
Thank you very much for completing this questionnaire. The information will be used as
part of the medical report that the doctor writes about you, so it is important that it is as
detailed and accurate as possible. Please sign and date the declaration:
10
Signed
Stewart durkin 13/07/2015
Dated
11