Name of person completing the form * Patient/Claimant name * Address * Gender * Male Female Date of birth * <input autocomplete="off" type="text" size="1" name="date-4" value="" placeholder="Choose Date" id="forminator-field-date-4-picker-_6419f3bd4ca11" class="forminator-input forminator-datepicker" data-required="1" data-format="dd-mm-yy" data-restrict-type="" data-restrict="" data-start-year="1923" data-end-year="2123" data-past-dates="enable" data-start-of-week="1" data-start-date="" data-end-date="" data-start-field="" data-end-field="" data-start-offset="" data-end-offset="" data-disable-date="" data-disable-range="" /> Occupation (including details of any change since the date of accident) * Currently at work? * Yes No Date last worked * <input autocomplete="off" type="text" size="1" name="date-1" value="" placeholder="Choose Date" id="forminator-field-date-1-picker-_6419f3bd4ca11" class="forminator-input forminator-datepicker" data-required="1" data-format="dd-mm-yy" data-restrict-type="" data-restrict="" data-start-year="1923" data-end-year="2123" data-past-dates="enable" data-start-of-week="1" data-start-date="" data-end-date="" data-start-field="" data-end-field="" data-start-offset="" data-end-offset="" data-disable-date="" data-disable-range="" /> Right or left hand dominant? * Right Left Height (cm) * Weight (kg) * BMI (and details of any change since accident) * Date of accident/injury * <input autocomplete="off" type="text" size="1" name="date-2" value="" placeholder="Choose Date" id="forminator-field-date-2-picker-_6419f3bd4ca11" class="forminator-input forminator-datepicker" data-required="1" data-format="dd-mm-yy" data-restrict-type="" data-restrict="" data-start-year="1923" data-end-year="2123" data-past-dates="enable" data-start-of-week="1" data-start-date="" data-end-date="" data-start-field="" data-end-field="" data-start-offset="" data-end-offset="" data-disable-date="" data-disable-range="" /> Years since date of accident * Months since date of accident * Brief accident details * Brief details of injury/injuries sustained * (Include steps taken immediately after accident and in subsequent few days) Date first treatment sought * <input autocomplete="off" type="text" size="1" name="date-3" value="" placeholder="Choose Date" id="forminator-field-date-3-picker-_6419f3bd4ca11" class="forminator-input forminator-datepicker" data-required="1" data-format="dd-mm-yy" data-restrict-type="" data-restrict="" data-start-year="1923" data-end-year="2123" data-past-dates="enable" data-start-of-week="1" data-start-date="" data-end-date="" data-start-field="" data-end-field="" data-start-offset="" data-end-offset="" data-disable-date="" data-disable-range="" /> From who was it received? * Were you hospitalised? * Yes No If hospitalised where? * Duration of inpatient stay? Total length of absence from work (start date and end date) If absence is ongoing is it due to the accident? Are you in other work? * Yes No Number of GP visits approximately * Number of specialist/consultant visits * Identity of specialist/consultant(s), if known Treatment and Investigations completed to date (related to this accident/injury) X/Rays or MRIs * Injections * Surgery * Number of physiotherapy sessions, if any Any other treatments undertaken Present complaints (if any) Effects on work Effects on normal activities of daily living Effects on recreation & sports activities Pain at night and effect on sleep Any other relevant information Please select how you feel your condition/injury is currently affecting your ability in the following Mental health * Not Affected Mild Moderate Severe Profound Learning/Intelligence * Not Affected Mild Moderate Severe Profound Consciousness/Seizure * Not Affected Mild Moderate Severe Profound Balance/Co-ordination * Not Affected Mild Moderate Severe Profound Vision * Not Affected Mild Moderate Severe Profound Hearing * Not Affected Mild Moderate Severe Profound Speech * Not Affected Mild Moderate Severe Profound Continence * Not Affected Mild Moderate Severe Profound Reaching * Not Affected Mild Moderate Severe Profound Manual dexterity * Not Affected Mild Moderate Severe Profound Carrying/Lifting * Not Affected Mild Moderate Severe Profound Bending/Stooping * Not Affected Mild Moderate Severe Profound Sitting * Not Affected Mild Moderate Severe Profound Standing * Not Affected Mild Moderate Severe Profound Climbing stairs * Not Affected Mild Moderate Severe Profound Walking * Not Affected Mild Moderate Severe Profound Submit Form

Medico-Legal Form

Below you will find out Patient/claimant to complete in advance of appointment for medico-legal report, as well as some Frequently Asked Questions.

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FAQ 2

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FAQ 3

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What is Medico-Legal?

Medico-legal is…