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  [ *  mandatory fields]  
 
Name *
 
Address *
  Postcode *
 
Date & time of accident *
HEAD INJURIES
 
Did you hit your head at all?     
yes no    
 
Have you had any headaches?
yes no    
 
If yes, how frequent and how severe
 
Have you been dizzy at all or fainted?
yes no    
 
Have you felt any nausea or sickness?
yes no    
 
Any sensation of ``pins and needles'' or prickling? If any, where?
yes no    
 
Were you unconscious or concussed at all?
yes no    
 

Have you had any trouble with your eyes i.e. double vision or difficulty in focusing?  If yes, please give details. 
 
yes no
 
 

Can you remember all events up to the accident?
yes no    
 
Can you remember the accident itself clearly?
yes no
 
Can you remember all events after the accident?
yes no
 
PLEASE ANSWER ALL QUESTIONS BELOW
 
If any neck or back pain of any kind did it come on immediately or later and if later how much later?
 
 
How long have you had neck or back pain?
 
 
Is there any pain on extension or rotation of the neck?
yes no
 
Any other symptoms, i.e. headaches, pins and needles, etc.?
 
Are you now fully recovered?
yes no
 

FRACTURES
 
Did you suffer any fractures ?
yes no
 
If yes, what bones were fractured
 
Are you presently in a cast?
yes no
 
If so, how long is the cast expected to remain on?
 
 
Do you require crutches/wheelchair to be mobile?
yes no
 

MINOR INJURIES
 
Did you have any cuts or bruises at all?
yes no
 

If yes, please answer all questions below :
 
Your cuts - please describe in detail where they were, whether any stitches or sutures, how long, and whether they will leave a scar
 
Your bruises - please give full details where, how big, whether  heavy or light, and how long before they cleared up
 
Did you have any abrasions or grazes?
yes no
 
If yes, please give full details
 
SHOCK
 
Were you shocked at all?
yes no
 
If yes, please answer all questions below :
  Please supply full details and advise whether yet fully recovered
 
Have you experienced any difficulty in sleeping?
yes no
  GENERAL ENQUIRIES  
 
Please state Date of Birth
 
Were you taken to Hospital?
yes no
 
If yes, were you kept in at all and which Hospital?
 
What length of time were you in hospital?
 
Did you require surgery?
yes no
 
If so, what surgical procedure was carried out.
 
Have you seen your own Doctor?
yes no
 
If yes, his or her name and address, dates seen, treatment given, etc.
 
Have you any other symptoms at all? 
yes no
 
If so, please give details
 
Occupation/Name and address of employer
 
Have you lost any time off work? 
yes no
 
If so, did you lose earnings?
yes no
 
Your National Insurance Number is:
 
Any other information?
  Name & address of witnesses
 
I agree that the above information is true and correct to the best of my knowledge and belief at this time.
 
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