You are on page 1of 11

PLEASE COMPLETE & RETURN THIS DOCUMENT BY EMAIL

(48 HOURS) BEFORE YOUR MEDICAL APPOINTMENT

Pre-Medical Questionnaire
VERY IMPORTANT: Please complete and return by email 48 HOURS BEFORE
attending your medical – medicolegals@hotmail.co.uk.

About You
Full Name:

Stewart durkin

Date of Birth:

09/08/1988

Right or Left Handed:

right

Past Medical History
Have you had any previous accidents, injuries or health problems? Please list them here,
including when they occurred, what treatment was needed, and whether they still affect
you now. If you need more space, please continue over the page.
Previous Accidents?
When did it happen?
What injuries did you have?
Did you make a full recovery?
How long did your recovery take?

13th July 2015
I had sustained severe whiplash from left neck down
to arm and on back trapezius
No I havnt made a full recovery yet,
Recovery still ongoing

1

PLEASE COMPLETE & RETURN THIS DOCUMENT BY EMAIL
(48 HOURS) BEFORE YOUR MEDICAL APPOINTMENT
Physical Health?

I am normally am in very good health

Are you normally in good health?
Have you had any serious illnesses?
Have you had neck, back or
shoulder problems in the past?

Nope

Mental Health?

Nope no problems before

Nope

Have you had any problems with
anxiety or depression?

Current Medication?

Strong ibrophean

What treatments do you take?

2

PLEASE COMPLETE & RETURN THIS DOCUMENT BY EMAIL
(48 HOURS) BEFORE YOUR MEDICAL APPOINTMENT
The Accident
This part of the form is for people who were in a vehicle at the time of the accident. If that
doesn’t apply to you, please describe your accident on the back of this page.
Date of Accident:

13/07/2015

Approx Time of Accident:

6pm to 7pm

Your Vehicle:

Ford focus zetec

What kind of vehicle were you in?

Your Position:

Driver

Driver, front or rear seat passenger?

Seat Belt:

Yes

Were you wearing a seatbelt?

Head Rest:

Yes

Was a headrest fitted?

Air Bag:

Not deployed

Was there one? Did it deploy?

Your Vehicle’s Movement:

Moving

Moving, stationary or turning?

Your Vehicle’s Location:

Right side inner of roundabout

Roundabout, traffic lights etc.

The Impact:
Briefly describe how the accident
happened, the speed and force of it,
and which part of your vehicle was
hit.

near sinsburys roundabout. I was coming from
Pilgrims lane B186, Just before i approached the
roundabout i realised i needed to go back the way i
came to get my phone charger so i indicated to go
right head back on myself to pilgrims lane b186
travelling at 15-20 mph. As i passed the first turn off
"Arterial Rd North Stifford" A lorry pulled out on my
left, i could not see the driver as the lorry was a
european left hand drive and failed to give way. I
beeped to make him aware i was there but As i
slowed down t i tried to move over as close to the
round about as possible but the lorry was incorrectly
postioned on my lane and collided with my vehicle
hitting my car on the left side wheel arch. The lorry
then drove off heading towards " Arterial Rd West
thurrock" while i was beeping him to pull over the
lorry continued to ignore me. As i followed him to the
next round about he did a u-turn at the next round
about to come back to the crash scene then pulled
over to the left, i then confronted the driver. The
driver admitted liability and filled out a insurance
claim form which he could not read as he was
romanian and the insurance document was in
portugal. ,We filled out the document togther and
signed the document. I have sustained severe
3

PLEASE COMPLETE & RETURN THIS DOCUMENT BY EMAIL
(48 HOURS) BEFORE YOUR MEDICAL APPOINTMENT
whiplash prior to the accident resulting not fit for
work.

Expecting the accident:
Were you expecting to be hit?
Did you brace for impact?

Damage to Your Vehicle:

No I wasn’t
Yes
Still drivable luckily

How badly damaged was it?

Thrown at Impact:

Side to side

How were you thrown at impact?

Get Out of Vehicle:

no

Did you need any help to get out?

4

PLEASE COMPLETE & RETURN THIS DOCUMENT BY EMAIL
(48 HOURS) BEFORE YOUR MEDICAL APPOINTMENT
Initial Injuries and Symptoms
Please describe the injuries or symptoms you noticed at the time of the accident. Include
both physical and any psychological symptoms you experienced. If you need more space,
please continue on the other side of this page. An example has been completed to guide
you.
Injury or Symptom:

Initial Severity:

Current Status:

Briefly describe what you felt.

How bad was it at first?
Mild, Moderate, Severe

How bad is it now?
Mild, Moderate, Severe
If it has resolved, how long after the
accident did it resolve?

Example: Neck Pain

Moderate

Cleared up after 3
months.

Neck pain to arm

severe

mild

Back pain

severe

moderate

Later Symptoms
Please describe any symptoms that came on some time after the accident.
Symptom:

Delay:

Briefly describe what you felt.

How long
after the
accident
did it
start?

Initial
Severity:
How bad was
it at first?
Mild,
Moderate,
Severe

Current Status:
How bad is it now?
Mild, Moderate, Severe
If it has resolved, how long did it take
to resolve?

Example: Back Pain

3
days

Moderat
Still stiff and sore.
e

Neck pain

24 hours

severe

Back pain

24 hours

severe

Anxiety getting into a
vehicle

instant

moderate

Really stiff and sore could not
work. It still is moderate to
mild
Mild, 3 months resolved
I still get anexity attacks when
driving when a lorry gets close
sometimes I have to pull over.
5

PLEASE COMPLETE & RETURN THIS DOCUMENT BY EMAIL
(48 HOURS) BEFORE YOUR MEDICAL APPOINTMENT
Initial Treatment
What treatment did you receive on the day of the accident?
Treatment at the Scene:
Did you need any?

no

Yes/No

Who treated you?

no

e.g. paramedic, passer-by

What was the treatment?

No, just shock

e.g. dressings, painkillers

Travel from the Scene:
Where did you go next?

Home then casualty next day

e.g. home, work, Casualty

How did you travel there?

Someonelse car, father in law

e.g. drove, got a lift, by ambulance

Other Treatment on the day of the accident:
Did you have any?
yes
Yes/No

Where did you have it?

home

e.g. Casualty, GP, work, home

What was the treatment?

painkillers

e.g. dressings, painkillers

Did you have any tests?

no

e.g. x-ray of neck

What were the results?

no

e.g. normal, fracture

Later Treatment
What other treatment have you received since the accident?
Treatment:

Timing:

Outcome:

What treatment have you had?
How many visits or sessions?
e.g. GP, physiotherapy

How long after the
accident did you start
the treatment?

How successful has it been?
e.g. physio improved neck pain
e.g. GP gave sick note and painkillers

Example:

3 days, 2
weeks, and 4
weeks

Got sick note,
painkillers and
physio referral.

36 hours

Had check and got stronger
pain killers and received sick
note and physio referral.

Attended GP 3
times

Went A and E romford
St georges hospital
Went gp clinic

24 hours

Had check and Got pain killers

6

PLEASE COMPLETE & RETURN THIS DOCUMENT BY EMAIL
(48 HOURS) BEFORE YOUR MEDICAL APPOINTMENT
Physiopherathpy

3 months after

It has been successful but is
still remaining .

Effect on Work
How has the accident affected your work?
If you have more than one job, please give details on the back of this page.
What is your job?

chef

e.g. taxi driver

Normal hours per week:

60

e.g. 40 hours

How much time off?

2 weeks, couldn’t afford more

e.g. none, 2 weeks, still off?

Light Duties?
For how long? Duties still light?

Reduced Hours?

Moved from running around the kitchen to peeling
veg.
1 month

For how long? Hours still reduced?

Lost Job?

no

Why? What happened?

Changed Job?

no

Why? What do you do now?

Effect on Travel
Have you had any problems as a driver or a passenger?
As a Driver:
Any pain or discomfort?
Yes/No
How severe has it been?
How long has it lasted?

Yes, going onto round abouts and turning corners,
turning my neck it was sore.

Any anxiety?

Yes

Yes/No
How severe has it been?
How long has it lasted?

Its been hard and severe
Its still on going I get anexity when near a lorry

As a Passenger:
Any pain or discomfort?

Yes

Yes/No
How severe has it been?
How long has it lasted?

Moderate
Its lasted a while

7

PLEASE COMPLETE & RETURN THIS DOCUMENT BY EMAIL
(48 HOURS) BEFORE YOUR MEDICAL APPOINTMENT
Any anxiety?

I get anexity still as keep thinkinh of the accident

Yes/No
How severe has it been?
How long has it lasted?

8

PLEASE COMPLETE & RETURN THIS DOCUMENT BY EMAIL
(48 HOURS) BEFORE YOUR MEDICAL APPOINTMENT
Home Situation
Who lives with you at home?
Adults:

Partner

e.g. partner
e.g. parents

Children:
How many?
What are their ages?

1
And age of 2

Effect on Home Life
How has the accident affected your home life?
If there have been any problems, please list them below.
Problem:

Current Status:

Briefly describe the problem.
e.g. housework, shopping, sport.
e.g. missed out on holiday (include destination) or
special event.

How bad was it to start with?
How bad is it now?
If it has resolved, how long did it take to resolve?

Example: Could not do

It settled after 3 weeks, but
I still have problems with
heavy items.

shopping because of
shoulder pain. Husband had
to carry the bags.

Couldn’t do housework was on house rest I was on sofa for a while. 2 weeks resting
but couldn’t afford to take any more time
off. Its mild.

Couldn’t pick up my own CHILD

I couldn’t lift my daughter to cuddle her
because I was in a lot of pain but now its
mild and I can. It took 3 weeks.

Couldn’t get into a car for a while

It was severe to start with and the anexity
but after 3 weeks I got into a car but I
still have the anexity attacks.

Could not go shopping

I couldn’t lift any bags at all so we got
home delivery. I go shopping in car but
took 1 month

9

PLEASE COMPLETE & RETURN THIS DOCUMENT BY EMAIL
(48 HOURS) BEFORE YOUR MEDICAL APPOINTMENT
Other Information or Comments
Please use this space to add any other information or comments you wish:
The day of the accident I was in shock so I did not feel in pain but 24 hours later after I
woke up in the morning , I felt it. It was like I got hit with a hammer from my neck down
to my hand and all my back, I was stiff and sore all through out.
I took time off work to recover I couldn’t drive, I couldn’t do anything, I couldn’t even
pick up my own child, couldn’t do shopping. But I was loosing money and statuoury
sick pay doesn’t cover rent unfortunately and I had a family to support. So I had to reutrn
to work still in pain.
Whenever I get into a car or vehicle and I see a lorry I get nervous and start have anxiety
attack I start to feel really sick likes its going to happen all over again.
Physio has helped me but I still have damaged soft tissue I don’t know how long it will
take to fix.

Final Declaration
Thank you very much for completing this questionnaire. The information will be used as
part of the medical report that the doctor writes about you, so it is important that it is as
detailed and accurate as possible. Please sign and date the declaration:
10

PLEASE COMPLETE & RETURN THIS DOCUMENT BY EMAIL
(48 HOURS) BEFORE YOUR MEDICAL APPOINTMENT
I confirm that the information given in this questionnaire is a true and accurate
description of the circumstances and injuries of my accident.

Signed
Stewart durkin 13/07/2015

Dated

11