This Questionnaire should take 10-15 minutes, and will greatly speed up the examination process.

This questionnaire is designed for the clients that have had road traffic accidents. If you feel that this does not apply to your accident please contact us via the ‘contact’ tab above.

Please note that questions marked with an asterisk* need to be filled in to proceed with the questionnaire.

Title* Mr
Mrs
Miss
Ms
Master
Dr
Rev

Name*

Surname*

Telephone Number

Date Of Birth*

Accident Date

Weight and unit (e.g. 10stone or 63kg)

Height and unit (e.g. 5.7foot or 170cm)

Have you had any previous accidents? – If so please specify when and how long it took you to recover

Have you had any serious illnesses? – If so please specify when and how long it took you to recover

Have you ever felt your current symptoms in the past? – If so please specify when and how long it took you to recover

What time was the accident?* Morning
Lunchtime
Afternoon
Evening
Night

What was the road like?* Dry
Wet
Icy

How was the visibility?* Good
Poor

What vehicle were you in?* Car
Van
Lorry
Bus
Motorbike
Bicycle
4×4
Other? – Please Specify Below

Other?

Position in the vehicle* Driver
Front Passenger
Rear Passenger
Rider (Motorbike)

Were you wearing a seatbelt?* Yes
No – If no please specify below

Did you have an exemption from wearing a seatbelt?

Was there a head rest fitted?* Yes
No
Unknown

Were there any air bags fitted?* Yes and they deployed
Yes but they did not deploy
No

Was your vehicle moving at the time of impact?* Moving
Stationary
Turning

Expecting the impact?* Yes
No

Which direction were you facing?* Forwards
Left
Right
Reading
Sleeping

Where did the accident occur?* Main Road
Minor Road
Roundabout
Traffic Lights
Junction
Queue of Traffic
Motorway
Car Park
Other? – Please Specify Below

Other?

Were you hit by the other vehicle, or did you collide with it?* Hit By
Collided With

What was the other vehicle?* Car
Van
Lorry
Bus
Motorbike
Bicycle
4×4
Other – Please Specify Below

Other?

What was the estimated speed of the impact? Low
Medium
High
Unknown

Which side of your vehicle was impacted?* Front
Driver's side (Right side)
Passenger's side (Left side)
Rear

How badly damaged was your vehicle?* Minor
Moderate
Extensive
Written off

How were you thrown at impact?* Forward
Backward
Forward & Backward
Sideways
In all directions

Did you need any help to get out of the car?* Yes
No

Other Accident Comments?

Please try to group your symptoms where possible – e.g. bruising to the left leg, left hip and pelvis rather than three separate symptoms.

Where were you injured? (First Symptom)*

When did you first notice the symptom? (First Symptom)*

How severe was the pain at its worst? 1-very mild/10-very severe (First Symptom)* 1
2
3
4
5
6
7
8
9
10

How is the pain now? 1-very mild/10-very severe (First Symptom)* Resolved
1
2
3
4
5
6
7
8
9
10

Where were you injured? (Other/Second Symptom)

When did you first notice the symptom? (Other/Second Symptom)

How severe was the pain at its worst? 1-very mild/10-very severe (Other/Second Symptom) 1
2
3
4
5
6
7
8
9
10

How is the pain now? 1-very mild/10-very severe (Other/Second Symptom) Resolved
1
2
3
4
5
6
7
8
9
10

Where were you injured? (Other/Third Symptom)

When did you first notice the symptom? (Other/Third Symptom)

How severe was the pain at its worst? 1-very mild/10-very severe (Other/Third Symptom) 1
2
3
4
5
6
7
8
9
10

How is the pain now? 1-very mild/10-very severe (Other/Third Symptom) Resolved
1
2
3
4
5
6
7
8
9
10

Where were you injured? (Other/fourth Symptom)

When did you first notice the symptom? (Other/fourth Symptom)

How severe was the pain at its worst? 1-very mild/10-very severe (Other/fourth Symptom) 1
2
3
4
5
6
7
8
9
10

How is the pain now? 1-very mild/10-very severe (Other/fourth Symptom) Resolved
1
2
3
4
5
6
7
8
9
10

Other Symptoms? Please note them here in a similar format to those above

Who attended the accident?* None
Paramedics
Police
Fire Service
First Aider
Doctor

Where did you go after the accident?*

How did you get there?*

Have you been to hospital?* Yes
No

If you have attended hospital, how long after the accident was your visit?

If you have attended hospital, what Treatment did you receive? Painkillers
Advice
A sick note

Did you have any X-rays or scans? if so on what part of your body and what was the result?

Have you been to see your local doctor/GP?* Yes
No

If you have attended your local doctor/GP, how long after the accident was your visit?

If you have attended your doctor, what Treatment did you receive? Painkillers
Advice
A physiotherapy referral
A sick note

Did you take any painkillers?* Yes, and I still take them regularly
Yes, but now I take them occasionally
No I didn't take any
Yes but now I have stopped – If so please specify duration below

How long did you take painkillers?

Have you had any Physiotherapy?* Yes
No

If you have had physiotherapy, roughly how long after the accident did you start?

If you have had physiotherapy, roughly how many sessions have you had up to now?

If you have had a course of physiotherapy, is this still continuing or has it now finished?

What was your occupation at the time of the accident?*

(Home-makers and Unemployed clients enter 0 hours and no time off)

How many hours a week do you work?*

Did you have to take any time off of work?*

Did you have to work any light duties or reduced hours?*

Have you had to leave or change your occupation due to the accident? was it related?

Are you anxious when you drive?* None
Mild
Moderate
Severe

Are you anxious when your a passenger in a car?* None
Mild
Moderate
Severe

Is there any discomfort when you drive?* None
Mild
Moderate
Severe

Is there any discomfort when your a passenger in a car?* None
Mild
Moderate
Severe

Who do you live with?* Alone
Parents
Spouse
Partner
Friends
Children
Family

Tick the following aspects of your home life that may have been affected* None
Cooking
Cleaning
Childcare
DIY
Gardening
Hoovering
Housework
Lifting items
Personal care
Sex
Shopping
Sleep
Social Life

Tick the following aspects of your home life that are still affected* None
Cooking
Cleaning
Childcare
DIY
Gardening
Hoovering
Housework
Lifting items
Personal care
Sex
Shopping
Sleep
Social Life

Do you play any sport?* Yes
No

If yes which sports?

Was your ability to play these sports restricted? for how long?

Did you miss any events or holidays due to the accident?* Yes
No

If yes, please give details.

Other Comments?


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