All information given remains confidential and is held securely by Medicolegal Partners Limited in accordance with the General Data Protection Regulation 2018. The information helps to simplify and speed up the medicolegal report writing process and is in no way a substitute for a full consultation and examination.

Please complete the details on this form so that we can pass it to Dr Jenner ahead of your consultation. It is important for Dr Jenner to compare information regarding your activities of daily living before and after the incident. This information, alongside further discussion at your consultation and the physical examination, will be incorporated into the report that Dr Jenner is writing.

Please amend this document in Word and email it back to us. If this is too difficult, call 0207 118 0650 and one of our team will complete the form over the phone with you.

1. Name:

2. Date of your consultation with Dr Jenner?

3. Height and weight:

Pre-Index accident/event  
Post-Index accident/event  

4. Do you drink alcohol, smoke cigarettes or take recreational drugs?

Per weekCigarettesType of alcoholic drinkEpisodes of taking recreational drugs
Example4 per dayWine (20 units per week)Cannabis (0.5g per week)
Pre-Index accident/event Spirits 25ml (1 unit)Alcopops (1 unit)Champagne (1 unit)Wine 175ml (2.3 units)Beer 1pt (2.3 units)Cider 1pt (2.3 units)  
Post-Index accident/event Spirits (1 unit)Alcopops (1 unit)Champagne (1 unit)Wine 175ml (2.3 units)Beer 1pt (2.3 units)Cider 1pt (2.3 units) 

Any other relevant information:

5. Sleep

 Average bedtimeAverage rising timeHours of sleep per nightNumber of times wokenduring night
Pre-Incident accident/event    
Post-Incident accident/event    

            Any other relevant information:

6. Exercise

This is your opportunity to note alterations in any pre-incident exercise regime such as walking (with or without a dog), running, cycling, swimming, gym. Please use as much as space as you need.

Type of exercise (eg swimming, running, going to the gym)Description 
E.g SwimmingBefore the accident/event: I used to swim 10 lengths of a full-size pool twice a week. After the accident/event: I can only swim 2 lengths once a week.
  Before the accident/event:    After the accident/event  
  Before the accident/event:    After the accident/event  
  Before the accident/event:    After the accident/event  

Any other relevant information:

7. Hobbies and interest

 List everything that you like doing, both now and immediately before the incident, e.g. gardening, decorating, travel but excluding exercise noted above, regardless of whether it has changed because of the index-incident. If your hobby has had to change, explain how it has changed. Please use as much as space as you need.

E.g KnittingBefore the incident: I used to knit most evenings. After the incident: I can’t hold a knitting needle in my right hand so can’t knit at all
  Before the accident/event:    After the accident/event
  Before the accident/event:    After the accident/event

Any other relevant information:

8. What is your living situation now and has it changed at all since the index incident?

For example, did you used to live alone and now live with parent because you need support, or have you moved from a two-storey property to a single storey property because the stairs are too difficult?

 Pre-index accident/eventPost-index accident/event
For example3rd floor flat, with husband, daughter 6yrs. No mobility aids or adaptions.House, on two floors, with grandma, husband, son 22yrs, daughter 8yrs. I use a wheelchair for long journeys outside and there is a ramp to the front door.
House or flat  
On how many floors is it  
Who is in the household  
Children (ages)  
Do you need mobility aids (e.g. walking sticks, mobility scooter)  
Are there any adaptions (e.g. ramps, grab rails, toilet seat raises)  

9. Function

This section is designed to understand whether you have any limitations on performing certain common functions. For example, do you ache if you stand for too long or do you need to limit your car journeys because you can’t sit for too long? Do limitations in hand or arm function mean that you struggle to dry your hair or apply make-up? 

 Pre-index accident/eventPost-index accident/event
Eg Sittingeg No issuesEg Need to stand up after 20 minutes because of discomfort

Do you have any other functional issues that you want to share?:

10. Activities of Daily Living

This section is best done as percentages so if you did all of the cooking before the incident but now your partner does half of it, put ‘100% claimant’ in the pre-incident column and ‘50% claimant, 50% partner’ in the post-incident column. It will be helpful to your case to add detail as to why you can’t do something.

ActivityPre-accident/eventPost-accident/event (plus detail)
E.g. DIY100% claimant50% claimant  50% partnerI can no longer reach above my head to decorate.
Gardening/ Allotment   
Grocery Shopping  

Do you have any other issues regarding activities of daily living that you want to share?:

11. Formal or Informal Care

In addition to any help you have noted above, do you have any care requirements now or at any point since the incident? For example, using paid services of a carer/cleaner/gardener? Or a once of figure of how much a family or friends gives you a week. 

12. Driving

It may be that you have had difficulty driving since the accident/event. You may struggle to operate foot pedals or drive yourself for any length of time. To help us understand any change in driving habits, please complete the table below. 

Make and model of car   
The longest journey undertaken as a driver  
Average length of driving time without the need to stop (please explain why you need to stop, e.g. discomfort or concentration)  
Types and lengths of regular journeys undertaken (e.g. 30mins to work, 10 mins to shops, 1 hour to appointments, 3 hours to visit family)  

Do you have any other issues regarding driving that you want to share?:

13. Has your relationships with your parents/children/friends or work colleagues changed since the index incident?

This section is designed for you explain how the quality your various relationships has changed since the index accident/event. For example,  playing with grandchildren, not seeing work colleagues.

14. Has the incident affected your social life? If so, how?

15. Financial

This section is to understand any financial impact caused by your pain symptoms. 

Are you receiving any benefits? (please list them).

Has there been any other financial impact?

16. Employment:

What employment did you undertake for the five years PRIOR to the index incident?   

If yes, in what job role and for how many hours per week?

Were you employed AT THE TIME OF the index incident?   

If yes, in what job role and for how many hours per week?

Have you had to take any time off since the index incident?   

If yes, specify the periods of time off work.

Have you remained in that employment?   

If yes, in what job role and for how many hours per week?

Are you CURRENTLY employed?   

If yes, in what job role and for how many hours per week?

Have you adjusted your working practices since the index incident?

If yes, in what way (eg reduction in working hours, sedentary or light duties only, no lifting, no shift work etc)?

Do you believe that your career has been affected by the index incident?

If yes, in what way?

17. Have you previously been involved in any road traffic accidents or accidents in the workplace, regardless of whether there was a legal claim or not. If so, please can you share the details here. If the event was part of a claim, please include that information as well.

18. Do you have any photographs that you would like to share. If so, please send them over with dates and labels ahead of the consultation.