Step 1 of 7 14% Administrator Email REF*Claimant First Name*Claimant Last Name:*Address*Gender*MaleFemaleDate of Birth* Date Format: DD slash MM slash YYYY Occupation*(including details of any change since the date of accident)Currently at work?*YesNoRight or left hand dominant?*RightLeftHeight*Weight*BMI(and details of any change since accident date)Date of accident* Date Format: DD slash MM slash YYYY Examination date* Date Format: DD slash MM slash YYYY Total time elapsed since date of accident(date of accident to examination date Years/Months)Brief Accident DetailsBrief Details of Injury/Injuries Sustained (Include history of condition immediately after accident and in subsequent few days)Date first treatment sought Date Format: DD slash MM slash YYYY From who was it received?Was claimant hospitalised?YesNoIf hospitalised where?Duration of inpatient stay?Total length of absence from work - From Date Format: MM slash DD slash YYYY Total length of absence from work - To Date Format: MM slash DD slash YYYY If absence is ongoing is it due to the accident?YesNoWas/is the claimant’s absence period reasonable?YesNoNumber of GP visitsNumber of Specialist/ Consultant visitsIdentity of Specialist/ Consultant(s), if knownTreatment and Investigations to date(Type and name of investigations and results if available i.e. information regarding medications, dosage and changes to same since accident or in e.g. the last six months)Number of physiotherapy sessions, if anyX-Ray/MRI results(please comment on the results - specifically please indicate if the findings are age related, if it is likely the claimant would have experienced symptoms anyway in any event and if symptoms were activated/aggravated by the accident will they return to pre-accident state and if so when?) Please Submit the form here so we can progress to the next step. World Health Organisation (WHO) International Classification of Diseases (ICD)(https://www.who.int/classifications/icd/en/) (Dominant injury code or multiple codes if applicable should be input. All coding should be in the same format as per the following example; S 1 3 . 4 - sprain and strain of cervical spine)Relevant Medical History (including previous and subsequent accidents and clarification on any interaction of injuries)Relevant history?YesNoAggravation of pre-existing condition?YesNoIf yes please give nature of pre-existing conditionGive details of previous (or subsequent) accident history, if anyWas 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 scoreClinical Findings on Examination(Range of movement(s)) Please Complete This Section Only if a Claimant has suffered Neck Pain or Whiplash Associated Disorder (WAD)Findings as at time of examinationAssessment of cervical range of motionNormalAbnormalPalpation for consistent tendernessPresentAbsentNeurological signsPresentAbsentFollowing Assessment claimants should be classified according to the Quebec Task Force (QTF) Classification of GradesIndicate the Whiplash Associated Disorder (WAD) GradeWAD 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 HealthNormalMildModerateSevereProfoundLearning/IntelligenceNormalMildModerateSevereProfoundConsciousness/SeizureNormalMildModerateSevereProfoundBalance/Co-ordinationNormalMildModerateSevereProfoundVisionNormalMildModerateSevereProfoundHearingNormalMildModerateSevereProfoundSpeechNormalMildModerateSevereProfoundContinenceNormalMildModerateSevereProfoundReachingNormalMildModerateSevereProfoundManual DexterityNormalMildModerateSevereProfoundCarrying/LiftingNormalMildModerateSevereProfoundBending/StoopingNormalMildModerateSevereProfoundSittingNormalMildModerateSevereProfoundStandingNormalMildModerateSevereProfoundClimbing StairsNormalMildModerateSevereProfoundWalkingNormalMildModerateSevereProfound Opinion/General Comments and Latest PrognosisIndicate 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/disability1. None of the symptoms/disability2. A small proportion (≤ 25%) of the symptoms/disability3. A moderate proportion (50%) of the symptoms/disability4. Most (≥ 75%) of the symptoms/disability5. All of the symptoms/disabilityComment FurtherAre further investigations required?YesNoDetails of further investigationsHave all reasonable steps been taken to alleviate symptoms/disability?YesNoIf all reasonable steps have not been taken to alleviate symptoms/disability please elaborateIs a full recovery expected?YesNoAre late complications expected?YesNoIf a full recovery is not expected please detail the likely effects on lifestyle/workEstimated total time period from the date of accident to full recoveryYears/MonthsAre further Specialist reports recommended?YesNoIf further Specialist reports are recommended please specifyAnticipated Future Treatment Required(Include approximate future treatment costs if applicable)Summary/Additional Information Completed By Completion Date Date Format: MM slash DD slash YYYY
