Mayo Medical Centre, Lawn Rd, Castlebar, Co. Mayo
Call Us
094 90 20202
Email Us
info@tmmc.ie
About US
Piab Medical Assessment Form
Step
1
of
3
33%
Do you have any Covid symptoms
Yes
No
GDPR Consent
I give my consent for my personal data and medical files to be used in this questionnaire.
This field is hidden when viewing the form
Administrator Email
REF
Claimant First Name
*
Claimant Last Name:
*
Address
*
Gender
*
Male
Female
Date of Birth
*
Occupation
*
(including details of any change since the date of accident)
Currently at work?
*
Yes
No
Right or left hand dominant?
*
Right
Left
Height
*
Weight
*
Date of accident
*
Appointment/Examination Date
*
Total time elapsed since date of accident
(date of accident to examination date Years/Months)
Brief Accident Details
Brief Details of Injury/Injuries Sustained
(Include history of condition immediately after accident and in subsequent few days)
Date first treatment sought
From who was it received?
Was claimant hospitalised?
Yes
No
If hospitalised where?
Duration of inpatient stay?
Total length of absence from work - From
Total length of absence from work - To
If absence is ongoing is it due to the accident?
Yes
No
Was/is the claimant’s absence period reasonable?
Yes
No
Number of GP visits
Number of Specialist/ Consultant visits
Identity of Specialist/ Consultant(s), if known
Treatment and Investigations to date
1. XRays/ MRI scans
Type of scan you had. Where did you have it done?
IMPORTANT: Please bring your scans with you on the day of your appointment.
2. Surgery
What surgery did you have and on what part of your body?
3.Physiotherapy
How many session did you have. Was your physiotherapy with a chartered physiotherapist?
Please check this box if you had
previous injury/ claim as a result of an accident?
Please detail previous injury/claim
Do you have any other medical conditions
*
Yes
No
Please detail your condition
Please Submit the form here so we can progress to the next step.
Relevant Medical History (including previous and subsequent accidents and clarification on any interaction of injuries)
Relevant history?
Yes
No
Aggravation of pre-existing condition?
Yes
No
If yes please give nature of pre-existing condition
Was pre-existing condition active/symptomatic before the accident?
Present Complaints
(Include effects on lifestyle/recreational and domestic/personal activities)
Visual Analogue Scale (VAS) for pain score
Clinical Findings on Examination
(Range of movement(s))
Please Complete This Section Only if a Claimant has suffered Neck Pain or Whiplash Associated Disorder (WAD)
Did this patient have a neck injury?
*
Yes
No
Findings as at time of examination
Assessment of cervical range of motion
Normal
Abnormal
Palpation for consistent tenderness
Present
Absent
Neurological signs
Present
Absent
Following Assessment claimants should be classified according to the Quebec Task Force (QTF) Classification of Grades
Indicate the Whiplash Associated Disorder (WAD) Grade
WAD 0 - (No neck pain, stiffness or any physical signs are noticed)
WAD I - (Complaints of neck pain, stiffness/but no physical signs)
WAD II - (Neck complaints & decreased range of motion & local tenderness in the neck)
WAD III - (Neck complaints & neurological signs)
WAD IV - (Neck complaints & fracture, dislocation or injury to the spinal cord)
If the claimant’s WAD Grade has changed during the course of their recovery, please comment on these changes:
Neck Disability Index (NDI) score (%)
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;
Mental Health
Normal
Mild
Moderate
Severe
Profound
Learning/Intelligence
Normal
Mild
Moderate
Severe
Profound
Consciousness/Seizure
Normal
Mild
Moderate
Severe
Profound
Balance/Co-ordination
Normal
Mild
Moderate
Severe
Profound
Vision
Normal
Mild
Moderate
Severe
Profound
Hearing
Normal
Mild
Moderate
Severe
Profound
Speech
Normal
Mild
Moderate
Severe
Profound
Continence
Normal
Mild
Moderate
Severe
Profound
Reaching
Normal
Mild
Moderate
Severe
Profound
Manual Dexterity
Normal
Mild
Moderate
Severe
Profound
Carrying/Lifting
Normal
Mild
Moderate
Severe
Profound
Bending/Stooping
Normal
Mild
Moderate
Severe
Profound
Sitting
Normal
Mild
Moderate
Severe
Profound
Standing
Normal
Mild
Moderate
Severe
Profound
Climbing Stairs
Normal
Mild
Moderate
Severe
Profound
Walking
Normal
Mild
Moderate
Severe
Profound
Opinion/General Comments and Latest Prognosis
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)
Degree to which you feel all of the claimant’s symptoms/disability
1. None of the symptoms/disability
2. A small proportion (≤ 25%) of the symptoms/disability
3. A moderate proportion (50%) of the symptoms/disability
4. Most (≥ 75%) of the symptoms/disability
5. All of the symptoms/disability
Comment Further
Are further investigations required?
Yes
No
Details of further investigations
Have all reasonable steps been taken to alleviate symptoms/disability?
Yes
No
If all reasonable steps have not been taken to alleviate symptoms/disability please elaborate
Is a full recovery expected?
Yes
No
Are late complications expected?
Yes
No
If a full recovery is not expected please detail the likely effects on lifestyle/work
Estimated total time period from the date of accident to full recovery
Years/Months
Are further Specialist reports recommended?
Yes
No
If further Specialist reports are recommended please specify
Anticipated Future Treatment Required
(Include approximate future treatment costs if applicable)
Summary/Additional Information
Completed By
Completion Date
