Conal Quah RTA

Conal Quah Medicolegal Questionnaire
Road Traffic Accident
Name*
First NameLast Name
Date of birth*
Occupation*
Height*
Weight*
Are you left- or right-hand dominant?*
LeftRightAmbidextrous
Marital status*
1. Accident Details
Date of accident (if you are unsure of the day please put 01 then month and year)*
DayMonthYear
Date
What was your position in the vehicle?*
Front Rear
Driver
Passenger side
Middle
What vehicle were you in? *
Was your vehicle moving at the time of impact?*
YesNoNot sure
If travelling, how fast? *
mph
Where did the accident occur?*
Main roadJunctionResidential roadRoundaboutDual carriagewayOther
What was the other vehicle?*
i.e. car, 4x4, van, HGV
Which area(s) of the vehicle were impacted?*
Front Rear
Driver's side
Passenger side
How badly damaged was your vehicle?*
Was your vehicle written off?*
YesNoOther
Was there more than one impact?*
YesNo
Were you hit by the other vehicle or collided with?*
Hit by other vehicleCollided withOther
What was the estimated speed of impact?*
i.e Low, medium, high
Were you aware of the impending collision?*
Time of accident*
MorningAfternoonEveningNight
What was the road like?
i.e. wet, dry, icy
What was the weather like?*
i.e. sunny, snowing, raining
How was the visibility?*
i.e. good, poor
Was your seatbelt fastened?*
YesNo
Was your seat fitted with a headrest?*
YesNoNot sure
Were airbags fitted in the vehicle?*
YesNoNot sure
If yes, did they deploy?
YesNo
2. Events Following the Accident
Which emergency services attended the scene (select one or more)*
PoliceParamedicsFire serviceNoneOther
Did you need help getting out of the vehicle?*
YesNo
If yes, by who?
Did you have any immediate discomfort at the time of accident? If yes, please specify where. *
Where did you go after the accident?*
How did you get there?*
i.e. taxi, walked
Were you treated by paramedics at the scene?*
YesNo
Where did you subsequently seek medical attention apart from at the scene?
i.e. hospital, GP, physiotherapy
If yes, by who?
When did you seek this medical attention?
Same dayNext dayWithin a weekOther
3. Injuries Sustained
Please try to group your symptoms where possible i.e. bruising to hip, leg and arm. Please also indicate which side affected i.e. left hip, right leg, left arm
Injury 1*
i.e. neck, upper back, lower back, other
When did you first experience the symptoms for the above injury?*
ImmediatelyFew hours laterLater that dayThe following dayOther
What % recovery has taken place since the accident?*
0 = no recovery at all, 100 = fully recovered
If not 100%, how would you rate your pain currently*

0
1
2
3
4
5
6
7
8
9
10
0 is No pain, 10 is Worst pain imaginable
Aggravating factors of pain*
What makes the pain worse i.e. exercise, sitting, standing
Relieving factors of pain*
What makes the pain better i.e. exercise, sitting, standing
Injury 2
i.e. neck, upper back, lower back, other
What % recovery has taken place since the accident?
0 = no recovery at all, 100 = fully recovered
When did you first experience the symptoms for the above injury?
ImmediatelyFew hours laterLater that dayThe following dayOther
If not 100%, how would you rate your pain currently

0
1
2
3
4
5
6
7
8
9
10
0 is No pain, 10 is Worst pain imaginable
Aggravating factors of pain
What makes the pain worse i.e. exercise, sitting, standing
Relieving factors of pain
What makes the pain better i.e. exercise, sitting, standing
Injury 3
i.e. neck, upper back, lower back, other
When did you first experience the symptoms for the above injury?
ImmediatelyFew hours laterLater that dayThe following dayOther
What % recovery has taken place since the accident?
0 = no recovery at all, 100 = fully recovered
If not 100%, how would you rate your pain currently

0
1
2
3
4
5
6
7
8
9
10
0 is No pain, 10 is Worst pain imaginable
Aggravating factors of pain
What makes the pain worse i.e. exercise, sitting, standing
Relieving factors of pain
What makes the pain better i.e. exercise, sitting, standing
Injury 4
i.e. neck, upper back, lower back, other
When did you first experience the symptoms for the above injury?
ImmediatelyFew hours laterLater that dayThe following dayOther
What % recovery has taken place since the accident?
0 = no recovery at all, 100 = fully recovered
If not 100%, how would you rate your pain currently

0
1
2
3
4
5
6
7
8
9
10
0 is No pain, 10 is Worst pain imaginable
Aggravating factors of pain
What makes the pain worse i.e. exercise, sitting, standing
Relieving factors of pain
What makes the pain better i.e. exercise, sitting, standing
Injury 5
i.e. neck, upper back, lower back, other
When did you first experience the symptoms for the above injury?
ImmediatelyFew hours laterLater that dayThe following dayOther
What % recovery has taken place since the accident?
0 = no recovery at all, 100 = fully recovered
If not 100%, how would you rate your pain currently

0
1
2
3
4
5
6
7
8
9
10
0 is No pain, 10 is Worst pain imaginable
Aggravating factors of pain
What makes the pain worse i.e. exercise, sitting, standing
Relieving factors of pain
What makes the pain better i.e. exercise, sitting, standing
Other injuries
4. Treatment and Investigations
Have you received any treatment? (i.e. physiotherapy, surgery, plastering)*
YesNo
If yes, what type of treatment did you receive?
PhysiotherapyChiropracticOccupational therapyAcupunctureSurgeryPlasteringOther
How long after the accident did the treatment commence?
How many sessions have been completed to date?
Has the treatment been completed?
YesNo
Has the treatment been helpful?

1
2
3
4
5
1 is Not at all, 5 is Extremely
Treatment comments
Have you had any X-rays or scans?*
YesNo
If yes, please specify area of body and type of scan
i.e. X-ray, CT, MRI, Ultrasound
Did you take any painkillers?*
YesNo
If yes, please give the name of the painkillers
5. Effect on Employment
Were you off work following the accident?*
YesNoN/A - unemployedOther
If yes, please specify how long
Were you put on light duties when you returned to work?*
YesNoN/AOther
If yes, please specify how long
Which work activities still cause you discomfort (if any)?
6. Effect on domestic life
Which of the following day-to-day activities still cause discomfort (select one or more)*
NoneCookingCleaningChildcareDIYGardeningHooveringGeneral houseworkLifting itemsPersonal care (washing etc.)SexSleepShopping
7. Effect on social/recreational activities
Are there any social or recreational restrictions since the accident (if yes, please give details)?*
i.e. gym, sports
8. Psychological effects
Do you experience any nightmares or flashbacks?*
YesNo
How frequent were they?
When did it resolve?
9. Travel anxiety
Do/did you suffer from any travelling anxiety following the accident?*
Yes - ongoingYes - resolvedNo
If resolved, how long were you affected?
Is there any discomfort when you drive or as a passenger (select one or more)*
Yes - when drivingYes - when a passengerNo
If yes, please give details
10. Social history
I live with*
Do you smoke?*
YesNo
Do you drink alcohol?*
YesNo
11. Other accident/claims
Do you have any past history of accidents or claims?*
YesNo
If yes, please give details
12. Past history of relevance
Is there any past history of problems related to the injuries sustained prior to the accident occurring?
YesNo
If yes, please give details.
13. Further Information
Please add below any further relevant information you would like covered in your report below
14. Declaration
I declare that all of the above information is a true account of the injuries sustained following the index accident.
Signature
Clear
Thank you for taking the time to complete this questionnaire

Kind regards,
Mr Conal Sean Linn Quah MBChB FRCSed (Tr&Orth)
Consultant Traumna and Orthopaedic Surgeon

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Should be Empty:

	Front	Rear
Driver
Passenger side
Middle

	Front	Rear
Driver's side
Passenger side

Conal Quah Medicolegal Questionnaire

1. Accident Details

2. Events Following the Accident

3. Injuries Sustained

4. Treatment and Investigations

5. Effect on Employment

6. Effect on domestic life

7. Effect on social/recreational activities

8. Psychological effects

9. Travel anxiety

10. Social history

11. Other accident/claims

12. Past history of relevance

13. Further Information

14. Declaration