Personal Injury Questionnaire Slip and Trip / Workplace

Name*
Address*
Postcode*
Email*
Date and 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?	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/ Address of employer
Have you lost any time off work?	Yes No
If so, did you lose earnings?	Yes No
Your National Insurance No. is
Any other information?
Name and 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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