TO BE COMPLETED AND RETURNED BEFORE YOUR MEDICAL CONSULTATION OR YOUR EXAMINATION MAY BE CANCELLED AND A CHARGE WILL INCUR. THIS FORM CAN ALSO BE COMPLETED DIRECTLY FROM OUR WEBSITE

RETURN ADDRESS: MEDICOLEGAL ASSOCIATES, 1 FRANCES COTTAGES, DENBY ROAD, COBHAM, SURREY KT11 1JT

All information given remains confidential and is held securely by Medicolegal Associates Limited in accordance with the Data Protection Act 1998.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. The outcome will be based on the information you have provided.Medicolegal Associates Limited accepts no responsibility for advice/information given relating to any incomplete, inaccurate or incorrect information you have provided.

Personal Details:

1. Name (including title) and address:

2. Daytime Telephone Numbers:

3. Email:

4. Age: 5. Gender:

History Section:

6. Date of the accident/incident

7. Brief summary of accident/incident

8. Site of the pain (e.g. arm/lower back/neck)

9. Character of the pain (e.g. sharp, burning, pricking, stabbing, aching etc)

10. When did the pain start?

11. How often do you get the pain? (e.g. continuous/daily/hourly etc)

12. Does the pain radiate to any other part of the body?

13. What things aggravate the pain? (e.g. standing/walking etc)

14. What things relieve the pain?

15. What medication (tablets/drugs) are you currently taking for your pain?

16. What other symptoms are linked to the pain? (stiffness/disability/depression/anxiety etc)

17. Do you have any medical illnesses? (asthma/diabetes/high blood/pressure etc)

18. What previous surgeries have you had? (e.g. appendix/hip replacement etc)

Treatments for pain:

What treatments have you had and their outcome? (e.g. had 2 epidurals but effect lasted only a few weeks). Treatments include:

Treatment / Outcome
Medication:
Physiotherapy:
Psychological/Psychiatric Treatments:
Alternative Medicine e.g. acupuncture, homeopathy etc:
Pain Management Procedures e.g. Nerve blocks, epidurals, facet joint injections, botox:
Surgery:
Advanced pain management techniques (e.g. spinal cord stimulator)

Employment and Activities of Daily Living:

VERY IMPORTANT PLEASE NOTE: Complete this section in some detail as it provides your opportunity to tell the court how the pain you have or had impacts your life in your own words. This section is not designed for you to give a medical history,but to help us and the court understand if and how your life has changed as a result of the accident/incident and the pain you are now suffering or have suffered. PLEASE COMPLETE EVERY QUESTION.

Employment/Working Life:

19.Are you currently employed? YES/ NO

If so, in what role and for how many hours a week?

20.Were you employed at the time of the accident/incident in question? YES / NO

If so, in what role and for how many hours a week?

21.Were you employed prior to the index accident/incident? YES / NO

If so, in what role and for how many hours a week?

22.Have you needed to take time off since the accident/incident in question? YES / NO

If so, please specify the duration and number of times you have been off work:

23.Has your employer been sympathetic to your injuries? YES / NO

Please specify:

24.Have you needed to change your working hours since the accident/incident in question? YES/ NO. If so, in what way?

25.Have you adjusted your working practices or arrangements since the accident/incident in question?(e.g. sedentary or light duties only/no lifting/no shift work etc) YES/ NO.

If so, in what way?

26.Do you believe your career has been affected by the accident/incident? YES/ NO.

If so, in what way?

27.Has your relationship with work colleagues changed since the accident/incident in question? YES/ NO. If so, in what way?

28. Any other information related to work/employment you would like us to know?

Home and Everyday Life:

29.Has your home and everyday life been affected since the accident/incident in question? YES/ NO. If so, in what way?

30. Has your ability to carry out day to day tasks been affected since the accident/incident in question? (e.g. housework/dressing/personal care/cleaning etc) YES / NO

If so, in what way?

31. Have you had to modify your home in any way since the accident/incident in question?

YES/ NO. If so, in what way?

32.Have you needed additional support at home since the accident/incident in question?

YES/ NO. If so, in what way?

33.Have your hobbies and interests changed since the accident/incident in question?

YES/ NO. If so, in what way?

34. Any other home/everyday information you would like to share with us?

Personal Relationships:

35.Before the accident/incident, were you married or in a relationship? YES/ NO.

36.Has this changed since the accident/incident in question? YES/ NO.

If so, in what way?

37.Has your physical/sexual relationship changed since the accident/incident in question? YES/ NO. If so, in what way?

38.Has your relationship with other family members changed since the accident/incident in question? YES/ NO. If so, in what way?

39.Has your relationship with friends changed since the accident/incident in question?

YES/ NO. If so, in what way?

40.Has your social activity changed since the accident/incident in question? YES/ NO.

If so, in what way?

41.Any other information regarding relationships you would like to share with us?

Any Other Relevant Information:

Please provide any other information you feel is relevant to your case:

BRIEF PAIN INVENTORY – Please complete this form fully

QUESTION / ANSWER
1 / Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains and toothaches). Have you had pain other than these every-day kinds of pain? / YES/NO
2 / On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts the most. / SEE FOLLOWING PAGE FOR DIAGRAM
3 / In the last 24 hours, rate your pain at its worst, between 0 and 10. (0 - no pain / 10 – pain as bad as you can imagine)
4 / In the last 24 hours, rate your pain at its best, between 0 and 10. (0 - no pain / 10 – pain as bad as you can imagine)
5 / On the average, rate your pain between 0 and 10.
(0 = no pain / 10 – pain as bad as you can imagine)
6 / Please rate your pain by number that tells how much pain you have right now.
(0 =no pain / 10 – pain as bad as you can imagine)
7 / What treatments/medications are you receiving for your pain?
8 / In the last 24 hours, how much relief have pain treatments or medications provided? Please give a percentage that most shows how much relief you have received.
(0% =no relief / 100% - complete relief)
9 / Indicate below the one number that describes how, during the past 24 hours, pain has interfered with your activities:
(0= does not interfere / 10 = completely interferes)
A / General activity
B / Mood
C / Walking ability
D / Normal work (includes work outside the home and housework)
E / Relations with other people
F / Sleep
G / Enjoyment of life

S-LANSS Pain Score

Leeds Assessment of Neuropathic Symptoms and Signs (self-completed):

The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale[1] has seven items consisting of five symptom items and two examination items. Usually, the examination items are done by a doctor but the modified version (the S-LANSS or self-report LANSS) allows people to do this themselves. The purpose of these scales is to assess whether the pain that is experienced is predominantly due to nerve damage or not. Both the LANSS and S-LANSS are scored out of 24; a score of 12 or more is strongly suggestive of neuropathic pain. Please note, however, that although the S-LANSS is a useful guide to the type of pain, it should only be viewed as an indicator, and not as a diagnosis.

NAME: DATE:

  • This questionnaire can tell us about the type of pain that you may be experiencing. This can help in deciding how best to treat it.
  • Please draw on the diagram below where you feel your pain. If you have pain in more than one area, only shade in the one main area where your worst pain is.

On the scale below, please indicate how bad your pain (that you have shown on the above diagram) has been in the last week (where ‘0’ means no pain and ‘10’ means pains as severe as it could be).

NONE 0 1 2 3 4 5 6 7 8 9 10 SEVERE PAIN

Below are 7 questions about your pain (the one in the diagram above).

  • Think about how your pain, as you have shown in the diagram, has felt over the last week. Put a tick against the descriptions that best match your pain. These descriptions may, or may not, match your pain no matter how severe it feels.
  • Only tick responses that describe your pain.

1. In the area where you have pain, do you also have 'pins and needles', tingling or prickling sensations?
a) NO - I don't get these sensations / (0)
b) YES - I get these sensations often / (5) (5)
2. Does the painful area change colour (perhaps looks mottled or more red) when the pain is particularly bad?
a) NO - The pain does not affect the colour of my skin / (0) (0)
b) YES - I have noticed that the pain does make my skin look different from normal / (5) (5)
3. Does your pain make the affected skin abnormally sensitive to touch? Getting unpleasant sensations or pain when lightly stroking the skin might describe this.
a) NO - The pain does not make my skin in that area abnormally sensitive to touch / (0)
b) YES - My skin in that area is particularly sensitive to touch / (3)
4. Does your pain come on suddenly and in bursts for no apparent reason when you are completely still? Words like 'electric shocks', jumping and bursting might describe this.
a) NO - My pain doesn't really feel like this / (0)
b) YES - I get these sensations often / (2)
5. In the area where you have pain, does your skin feel unusually hot like a burning pain?
a) NO - I don't have burning pain. / (0)
b) YES - I get burning pain often. / (1)
6. Gently rub the painful area with your index finger and then rub a non-painful area (for example, an area of skin further away or on the opposite side from the painful area). How does this rubbing feel in the painful area?
a) The painful area feels no different from the non-painful area. / (0)
b) I feel discomfort, like pins and needles, tingling or burning in the painful area that is different from the non-painful area. / (5)
7. Gently press on the painful area with your finger tip then gently press in the same way onto a non-painful area (the same non-painful area that you chose in the last question). How does this feel in the painful area?
a) The painful area does not feel different from the non-painful area / (0)
b) I feel numbness or tenderness in the painful area that is different from the non-painful area. / (3)

Scoring: a score of 12 or more suggests pain of a predominantly neuropathic origin

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[1]Source: Bennett, M et al The Journal of Pain, Vol 6, No 3 March , 2005 pp 149-158 The S-LANNS Score for Identifying Pain of Predominantly Neuropathic Origin: Validation for Use in Clinical and Postal Research The Journal 3.