Medico-Legal Assessment Questionnaire
Please complete this form to provide detailed information for your medico-legal assessment. All information will be treated confidentially.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Information (Phone and Email)
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Referring Party (e.g., Lawyer, Insurance Company)
Reason for Assessment / Nature of Legal Matter
*
Please provide a brief description of the incident or injury relevant to this assessment.
*
Medical History: Please list any relevant past or current medical conditions, surgeries, or treatments.
*
Current Symptoms and Functional Impact
*
Rows
Not at all
Mild
Moderate
Severe
Pain
1
2
3
4
Mobility limitations
5
6
7
8
Sleep disturbance
9
10
11
12
Concentration difficulties
13
14
15
16
Emotional distress
17
18
19
20
On a scale of 1 to 10, how would you rate your overall daily functioning since the incident?
*
Very Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very Poor, 10 is Excellent
Please indicate which of the following activities are affected by your condition (select all that apply):
*
Work/Employment
Household tasks
Self-care
Leisure/Social activities
Other
Please provide any additional comments or information you believe is relevant to your assessment.
Signature (please sign below to confirm your consent)
*
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