Accident/Assault/ Road Traffic Accident Questionnaire

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1 It is important that you provide as much information as you can remember. Where specific dates are unknown, please give approximations. Please use the section on the back page for any additional notes. 1. Please tick which of these events you suffered (if more than one please complete separate questionnaire(s)): Accident Assault Road Traffic Accident Other Please specify event if other 2. When did the event occur? Date 3. Please give details of the type of symptoms and injuries sustained you: a) experience now b) experienced in the past relating to this event (including approximate dates) 4. Have you suffered any anxiety/ stress (including post traumatic stress disorder) / depression as a result of this? If yes please complete a Mental/ Emotional Health Questionnaire in addition to completing this questionnaire 5. Please state when these symptoms were: a) first experienced Date Duration b) last experienced Date Duration Page 1 of 5

2 6. If your answer to the previous question does not make clear the duration and frequency of symptoms then please confirm: a) for how long you have suffered symptoms b) how often 7. Have you undergone any tests or investigations in connection with your symptoms? Test / investigation When By whom Results / diagnosis made 8. Have you had any time off work due to the event/ symptoms? Number of days Dates to to 9. Have you had to amend your work duties / hours as a result of the event/ symptoms? Date Details Page 2 of 5

3 10. Have you received any treatment e.g. medication / surgery etc: a) in the past? If yes please provide details including approximate dates: b) now? If yes please provide details: c) planned? If yes please provide details including approximate dates: 11. Please advise of any other symptoms you have experienced which you attribute to the accident/ assault/ road traffic accident/ other. 12. Have you submitted a claim for compensation as a result of injuries sustained in the accident/ assault/ road traffic accident/ other? If yes please provide details including what you claimed for, how much you claimed and when you claimed: Page 3 of 5

4 13. Are you awaiting any referrals / tests / investigations / checkups relating to the event/ symptoms? Date Details 14. Have you any residual pain, stiffness, discomfort, weakness and/ or problem associated with this injury/ condition? If yes please provide details: 15. Has a full recovery been made? If no please provide details: This questionnaire forms part of your application for membership of the Society. The Society would advise you to take care to include any material fact in this questionnaire. A material fact is one which could affect the terms of acceptance or the payment of any claim. If you do not tell us about a material fact this could lead to your application being declined and may result in any monies paid to the Society together with any claims made upon the funds thereof, being forfeited. If you are in any doubt as to whether a fact is material you should tell us about it as part of your application. If you wish to supply us with any additional information relating to this condition or there was insufficient space underneath the questions please use the Additional tes section at the end of the questionnaire to provide this information. Signed: Date: Page 4 of 5

5 Additional tes: Page 5 of 5

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