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standard-title Bennett PIAB Medical Assessment Form

Bennett PIAB Medical Assessment Form

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Step 1 of 3

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  • DD slash MM slash YYYY
  • (including details of any change since the date of accident)
  • DD slash MM slash YYYY
  • DD slash MM slash YYYY
  • (date of accident to examination date Years/Months)
  • (Include history of condition immediately after accident and in subsequent few days)
  • DD slash MM slash YYYY
  • DD slash MM slash YYYY
  • DD slash MM slash YYYY
  • Treatment and Investigations to date

  • Type of scan you had. Where did you have it done? IMPORTANT: Please bring your scans with you on the day of your appointment.
  • What surgery did you have and on what part of your body?
  • How many session did you have. Was your physiotherapy with a chartered physiotherapist?
Submit
  • Please Submit the form here so we can progress to the next step.

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  • Relevant Medical History (including previous and subsequent accidents and clarification on any interaction of injuries)

  • (Include effects on lifestyle/recreational and domestic/personal activities)
  • (Range of movement(s))
  • Please Complete This Section Only if a Claimant has suffered Neck Pain or Whiplash Associated Disorder (WAD)

  • Indicate the Whiplash Associated Disorder (WAD) Grade
  • Clinical Description of effects of Claimant’s Illness/Accident/Disablement – practitioners should indicate the degree, if any, to which the claimant’s condition is currently affecting his/her ability in the following;

  • Indicate the degree to which you feel all of the claimant’s symptoms/disability have been caused by the accident/event which is the subject of this claim; based on assessment of the injury as described by the claimant the accident/events accounts for (tick one box)
  • Years/Months
  • (Include approximate future treatment costs if applicable)
  • Completed By

  • DD slash MM slash YYYY
Submit

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