Medical Impairment Assessment Report Format
Mental and behavioural disorders assessment report template
1. Background
Client details
Name:
Address:
Claim Number:
Date of Accident:
Date of Birth:
Sex: Male Female
Marital status:
Country of birth:
Language spoken:
Interpreter required: Yes No
Occupation:
Employer:
Dominant hand: Left Right
Enclosures received:
2. Details of the assessment
Date of assessment:
Name of assessor:
Type of assessment:
Have you previously undertaken an assessment for this client: Yes No
Please record the details of all persons present at the time of this assessment. Include their name, contact details and relationship to the client.
3. Accident circumstances
Please include:
A description of the accident circumstances.
A detailed description of what immediate medical intervention was received by the client and at what hospital(s).
4. Medical history
General medical history
Please include details of:
All pre existing medical conditions, illnesses or injuries.
Whether or not these pre-existing conditions were aggravated by the transport accident and, if so, the extent of the aggravation.
Changes to the treatment or medication regime.
Dates of the original diagnosis and of the onset of any aggravation.
Whether the conditions have resolved and if so, an indication of when they resolved.
Any injury or illness that has developed subsequent to the transport accident including the cause, nature and course of the condition(s).
Whether the conditions have resolved and if so, an indication of when they resolved.
Any hereditary risk factors.
Social, family and other history
Please include:
Details of the client’s family unit.
Details of all support provided by the family
Details of all support provided outside the family unit.
Medication history
Including:
§ Name, dose and strength of medication taken before and after the transport accident
§ Relationship to accident (including any changes in dose post accident)
§ Expected duration of use.
Substance use history
Initial injury, treatment and progress
Please Include:
All injuries sustained in the transport accident and the initial treatment.
Subsequent treatment sought for those injuries
All new medical complaints or changing symptoms including the onset dates and changing treatment
Current medical complaints
Please include:
§ Current medical conditions, symptoms, treatment and causation.
5. Current psychiatric complaints
Please include:
The client’s mental and psychiatric state post accident
The client’s current psychiatric state
Details of the psychiatric/psychological treatment the client is receiving
Psychiatric history
In this section, please include comment on:
§ Any unrelated or pre-existing conditions identified
§ Whether the conditions have resolved or whether treatment for these conditions continues
Only those unrelated/pre-existing conditions aggravated by the transport accident need to be assessed.
Also include comment on:
§ Childhood development, upbringing
§ Any family history of medical or psychiatric illness
§ Current status of family members
§ Marital, relationship history, children
§ Scholastic and employment history
§ Past medical and psychiatric history
§ Cigarette, alcohol, and dug history
§ Medico legal history
§ Criminal history
§ Financial circumstances/concerns
6. Psychiatric examination
Diagnoses
Please provide details of:
Any psychiatric illness resulting from the transport accident that is not related to physical injury
Any psychiatric illness resulting from the effects of a transport accident related physical injury
Any psychiatric illness not related to the transport accident
Analysis of findings
Discussion
Is the psychiatric illness consistent with the accident circumstances?
Is a pre-existing psychiatric illness influencing the course of a current transport accident related psychiatric illness?
Please comment on the treatment and medication the client has received. Is current treatment and frequency of treatment reasonable? Should any other form of treatment be considered by the treater?
Is rehabilitation appropriate? If so, please elaborate.
Please comment on the client’s employability.
Neuro psychological
If not already performed, do you recommend a neurological or neuropsychological
assessment
Does the client have an associated neurological emotional disturbance?
Does the client have a psychiatric emotional disturbance?
Please estimate the client’s impairment levels.
Lifestyle evaluation
Please expand under the follow headings:
Mobility
Personal relationships
Work and home activities
How the medical condition affects the clients occupational and daily living activities (whether the client has worked/is back at work, is fit to return to work, type of work/potential to work, etc.)
The medical basis for any conclusion that the client is/is not likely to suffer injury/harm by engaging in occupational and daily living activities.
Leisure activities
7. Prognosis
Please consider the client’s future prospects and outcome with reference to:
Treatment
Motivation
Rehabilitation
Aging
Recovery time
Consultants are requested to include in the report the name of the client’s treating practitioner. This is required in cases where we are required to obtain additional information or relay recommendations made in medical reports.
8. Have all questions asked by the TAC been answered?