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Client submitted Questionnaire

Appointment Details

Date of Appointment(Required)

Client Title(Required)

Client Name(Required)

Date of Birth(Required)

Address(Required)

Post Code(Required)

Country(Required)

Phone No.(Required)

Client Gender(Required)

Male

Female

Dominant Hand(Required)

Left

Right

Marital Status(Required)

Dependents(Required)

Number of dependent children

End of client details

Appointment Type(Required)

RTA

Workplace injury

Other personal injury

Occupational Details

Was the Client in Employment at the Time of the Accident?(Required)

Yes

Employed options

Occupational Type(Required)

Employment Status(Required)

Not Employed

Enter details(Required)

Occupational status end

Was the Client in Education at the Time of the Accident(Required)

Yes

Study Type(Required)

General Health

Any previous medical problems(Required)

Yes

Please describe previous medical problems(Required)

Accident Details

Date of Accident(Required)

What time did the accident occur?(Required)

Other time of accident(Required)

RTC

Where did your accident occur?(Required)

Other location of accident(Required)

Where were you sitting?(Required)

Other seating(Required)

Protection(Required)

Seatbelt

Helmet

Reflective / protective clothing

Gloves

Boots

Other Protection

No protective gear

Other protective gear(Required)

Vehicular

What was client vehicle type?(Required)

Client vehicle type(Required)

What was other party vehicle type?(Required)

Other party vehicle type(Required)

Was client vehicle(Required)

Other client vehicle action(Required)

Where did the impact come from?

Front head-on

Rear

Passenger's Side / Left Side

Driver's Side / Right Side

Other type of impact

Other impact type(Required)

What was the speed of impact?(Required)

Speed of impact (mph)

Damage severity to Client's vehicle(Required)

What happenned to client?(Required)

Other impact to client(Required)

Pedestrian

What was the speed of impact to pedestrian?(Required)

Describe what happened to client(Required)

other injury

Location where accident/injury occurred(Required)

Circumstances of Accident/Injury(Required)

Treatment After Accident

Emergency Department visits(Required)

Yes

Number of ED visits(Required)

Hospital Specialist Clinics Visits (excluding physiotherapy(Required)

Yes

Number of Hospital Specialist visits(Required)

Type of Hospital Visits

GP visits after accident (remote or in-person)(Required)

Yes

How many times did client visit GP / speak to GP?(Required)

Any out of hours visits?(Required)

Yes

Number of GP OOH visits(Required)

Rehabilitation Provider(Required)

No rehab / therapy

Physiotherapist

Chiropractor

Osteopath

Other Rehab Provider

Other rehabilitation provider(Required)

How many Rehab Sessions (including remote)(Required)

Waiting for appointment

Attended

Number of Rehab Sessions(Required)

Medication(Required)

No medication

Paracetamol

Co-codamol / Codydramol

Dihydrocodeine/Codeine

Naproxen / Diclofenac

Ibuprofen

NSAID/other gel/cream

Took Other Medication

Other medication taken(Required)

Any other accidents in the past?(Required)

Yes

Hidden

Accident history

Please specify Month/Year if possible,(Required)

What injuries did client sustain in that accident?(Required)

How long after were they resolved?

Current Accident Symptoms/Injuries

Body area injured from accident (please tick all that apply)(Required)

Head/Face injuries (click to expand)

Head/Face injuries - tick all areas injured(Required)

Head - front (forehead)

Head - top

Head - back

Head - left side

Head - right side

Face - front

Face - left

Face - right

Neck Injuries (click to expand)

Neck injuries - tick all areas injured(Required)

Neck - left

Neck - right

Neck - centre/midline

Referred pain to left arm

Referred pain to right arm

Referred upper limb symptoms

Upper Back Injuries (click to expand)

Upper Back injuries - tick all areas injured(Required)

Upper Back - centre/midline

Upper Back - left

Upper Back - right

Lower Back Injuries (click to expand)

Lower Back injuries - tick all areas injured(Required)

Lower Back - left

Lower Back - right

Lower Back - centre/midline

Referred pain to left leg

Referred pain to right leg

Referred lower limb symptoms

Chest Injuries (click to expand)

Chest injuries - tick all areas injured(Required)

Chest - centre/midline

Chest - left

Chest - right

Abdominal injuries (click to expand)

Abdominal injuries - tick all areas injured(Required)

Abdomen - upper

Abdomen - lower

Abdomen - left

Abdomen - right

Shoulder/Upper Arm injuries (click to expand)

Shoulder/Upper Arm injuries - tick all areas injured(Required)

Shoulder - left

Shoulder - right

Upper Arm - left

Upper Arm - right

Elbow/Forearm Injuries (click to expand)

Elbow/Forearm injuries - tick all areas injured(Required)

Elbow - left

Elbow - right

Forearm - left

Forearm - right

Wrist/Hand/Fingers Injuries (click to expand)

Wrist/Hand/Fingers - tick all areas injured(Required)

Wrist - left

Wrist - right

Hand - left

Hand - right

Fingers - left

Fingers - right

Please state which fingers were injured.(Required)

Hip injuries (click to expand)

Hip injuries - tick all areas injured(Required)

Hip - left

Hip - right

Thigh injuries (click to expand)

Thigh injuries - tick all areas injured(Required)

Thigh - left

Thigh - right

Knees/Legs injuries (click to expand)

Knee/leg injuries - tick all areas injured(Required)

Knee - left

Knee - right

Leg - left

Leg - right

Ankle/Feet/Toes injuries (click to expand)

Ankle/fee/Toes injuries - tick all areas injured(Required)

Ankle - left

Ankle - right

Foot- left

Foot - right

Toes - left

Toes - right

Please state which toes were injured(Required)

Further information/comments on injuries

Driving related symptoms

Client experienced the following

Client doesn't drive

Anxiety or fear

Flashbacks

Physical Discomfort

Have these symptoms resolved?

Yes - fully resolved

No - still ongoing

If driving related symptoms resolved, after how long?(Required)

How is client feeling if the symptoms are still ongoing.(Required)

Effects on Daily Living

Hidden

If in employment

Time off Work(Required)

Yes

Duration off work(Required)

Did client get sick note?(Required)

Yes

Hidden

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Work pattern changes(Required)

No changes to work pattern

Light duties

Reduced hours

Working from home

Duration of work pattern change(Required)

Hidden

Section Break

Difficulties experienced at work

Pain

postural difficulties

reduced mobility / physical activity

reduced concentration

Still ongoing?

Yes

If difficulties at work resolved, after how long?

Hidden

Section Break

Domestic effects - problems experienced at home

cleaning

cooking

driving

ironing

looking after children

shopping

vacuuming

Self-care

Sexual well-being

Person helping with domestic and self-care problems

Domestic effects still ongoing?

Yes

If domestic effects resolved, after how long?

Effect on hobbies

Yes

Describe effect on hobbies(Required)

Effects on hobbies still ongoing?

Yes

If effects on hobbies resolved, after how long?

Hidden

Section Break

Type of sleeper client usually is

Good Sleeper

Moderate Sleeper

Poor Sleeper

Insomnia

Any effects on sleep after the accident?

Yes

Severity of sleep effects

mild

moderate

severe

Sleep effects still ongoing?

Yes

If sleep effects resolved, after how long?

Any other information related to accident

Exercise, leisure activities. Still ongoing. Tinme for resolution etc.