Inc_Que_Test | Clinical Psychology Enterprise Limited

Incident Questionnaire

Please be honest when completing this form. Most of the the questions are very straightforward.

Completing this questionnaire fully will be very helpful and save you time during the assessment interview.

Please confirm your answers by ticking the consent box at the end.

1General

Information

2Background Personal History

(BEFORE Accident)

BEFORE

the Incident

Description of

the Incident

AFTER

the Accident

General Information

1) Client Name(Required)

Your Name (required)

First Last

1.2) Client e-mail Address(Required)

Your Email Address (required)

Enter Email Confirm Email

2) Date of Accident(Required)

Date of Accident (required)

DD slash MM slash YYYY

3) Date of Birth(Required)

Date of Birth (required)

DD slash MM slash YYYY

4) Client Age

Age

5) Town/City living in now

Town/City living in now

6) Marital Status

Marital Status

Hidden

7) Number of Children

Number of Children

8) Children's Ages

Use the "Add Child" button below to add details for each of your children

Gender of Child	Child's Age	Actions

There are no Children.

Maximum number of children reached.

9) Town/City of Early Childhood

Town/City of Early Childhood

10.1) Number of Brothers

Number of Brothers

10.2) Number of Sisters

Number of Sisters

11) Job at time of accident

Job at time of accident

Background Personal History (BEFORE Accident)

12) Have you ever brought any compensation claims for injuries before (e.g. RTA, Work Accident, Medical Negligence etc.)

Have you ever brought any compensation claims for injuries before (e.g. RTA, Work Accident, Medical Negligence etc.)

12.1) Details of previous compensation claims (date and primary issue)

Details of previous compensation claims (date and primary issue)

Please note any significant life events (and dates):

13) a) Parents divorce

Parents divorce

13) a) i) Year of parents divorce

Year of parents divorce

14) b) i) Parents death - Father

Parents death - Father

14) b) i) i) Year of Father's death

Year of Father's death

14) b) ii) Parents death - Mother

Parents death - Mother

14) b) ii) i) Year of Mother's death

Year of Mother's death

Serious illness within the last 10 years (e.g. surgery, needing hospitalisation)

15) c) i) to me:

to me:

15) c) ii) to partner:

to partner:

15) c) iii) to my children:

to my children:

16) d) My Divorce/Separation

My Divorce/Separation

16) d) i) Year of Divorce/Separation

Year of Divorce/Separation

17) Other difficult events

Other difficult events

18) Have you ever been convicted of a criminal offence:

Have you ever been convicted of a criminal offence:

18.1) Date of offence

If 'Yes' - Date of offence

18.2) Details of criminal offence

Details of criminal offence

Before the Incident

Have you ever had any similar incidents before this one, however minor: (e.g. car accident, work accident, falls incident etc.)?

19) Prior accidents

Use the "Add Accident" button below to add details of previous car accidents.

Date of previous accident	Driver or Passenger	Any injuries	Time off work	Any psychological problems after this? (How long did they last?)	Actions

There are no Previous accidents.

Maximum number of previous accidents reached.

Have you ever been to your GP for any mood, anxiety or stress related problems at any time before this incident?

20) Have you ever been to your GP for any mood, anxiety or stress related problems at any time before this incident?

Use the "Add Problem" button below to enter details of each problem

Year	Problem	Actions

There are no Problems.

Maximum number of problems reached.

21) Were you prescribed any psychiatric medication (e.g. antidepressants) or referred to counselling?

Were you prescribed any psychiatric medication (e.g. antidepressants) or referred to counselling?

21) a) Details of medication or counselling

Details of medication or counselling

22) Have you ever seen a Psychologist or a Psychiatrist?

Have you ever seen a Psychologist or a Psychiatrist?

22) a) Please provide details

Please provide details

23) Have any immediate family had treatment for psychological/emotional difficulties or mental health problems?

Have any immediate family had treatment for psychological/emotional difficulties or mental health problems?

23) a) Details of any immediate family having treatment for psychological/emotional difficulties or mental health problems:

Please provide details

In the 12 months BEFORE the incident:

24) a) Did any stressful life events/problems occur in the 12 months before the incident?

Did any stressful life events/problems occur in the 12 months before the incident?

24) a) i) Stressful life events checklist - 12 months BEFORE incident

Stressful life events checklist - 12 months BEFORE incident

Work Accident (and injury)

Redundancy

Fear of Redundancy

Work Harassment or stress

Disciplinary Situation

Car Accident

Motorbike Accident

Cycle Accident

Pedestrian Accident

Significant Medical Illness

Hospital Stay

Medical Accident

Childbirth

Termination

House Move

Alcohol Misuse

Non-Prescribed Drug Use

Antidepressant Medication

Significant Financial Debts

Marriage

Divorce

Relationship problems or Separation

Neighbour Dispute

Bereavement or Serious Illness to Close Relatives / close friend

Problems with your children

24) a) iii) Details of problems with your children

Details of problems with your children

24) b) Did you have <b>any other</b> stressful life events - 12 months BEFORE incident?

Did you have any other stressful life events - 12 months BEFORE incident?

24) b) i) Details of any other stressful life events

Please give details

24) c) b) Were you taking any psychiatric medication at the time of the incident (e.g. anti-depressants, betablockers, sleeping tablets etc.)?

Were you taking any psychiatric medication at the time of the incident (e.g. anti-depressants, betablockers, sleeping tablets etc.)?

24) c) b) i) Details of antidepressants being taken

Details of antidepressants being taken

Brief Description of the Incident

25) Please describe in your own words what happened in the incident

Please describe in your own words what happened in the incident:

26.1) a) Were you driving?

Were you driving?

26.1) a) i) Who was driving?

Who was driving?

26.1) b) Were you a pedestrian?

Were you a pedestrian?

26.2) Approximate Speed of your vehicle (mph)

Approximate Speed of your vehicle (mph)

27.1) Were you a passenger?

Were you a passenger?

27.1) a) Type of passenger?

Type of passenger?

28.1) Were there other people involved (e.g. car passengers or colleagues)?

Were there other people involved (e.g. car passengers or colleagues)?

28.1) a) Details of other people involved:

Please give details

29) Were you stationary?

Were you stationary?

30) Were you wearing a seat belt?

Were you wearing a seat belt?

Was your collision:

31) Was your collision a rear collision

A rear collision

32) A vehicle approaching from the opposite direction

A vehicle approaching from the opposite direction

33) A vehicle emerging from a:

A vehicle emerging from a:

34) Did you lose consciousness?

Did you lose consciousness?

34) i) How long consciousness lost for?

How long for?

35) Were you trapped in any way?

Were you trapped in any way?

35) i) Details of being trapped:

Please give details:

36) What did you feel at the time of the incident/shortly afterwards:

What did you feel at the time of the incident/shortly afterwards:

Shock

Upset

Fear

Anger

Calm

Other

36) i) - Further details of how client felt at the time of the incident:

Further details

37) Describe in your own words how you felt when it happened

Describe in your own words how you felt when it happened

38) Were you seen by paramedics at the scene of the incident?

Were you seen by paramedics at the scene of the incident?

39) Did you go to hospital after the incident?

Did you go to hospital after the incident?

39.1) Which hospital?

Which hospital?

40) Were you admitted to a ward overnight?

Were you admitted to a ward overnight?

40.1) How many nights were you in hospital for?

How many nights were you in hospital for?

41) Did you visit your GP after the incident?

Did you visit your GP after the incident?

41.1) How long after the incident?

How long after the incident?

42) What were your main physical injuries?

What were your main physical injuries?

Neck

Shoulder

Headaches

Whiplash

Bruising

Teeth

Face

Back

Other

42.1) Further details of 'other' injuries

Further details of 'other' injuries

43) Did you have any time off work after the incident?

Did you have any time off work after the incident?

43.1) How long?

How long?

44) Was your sleep affected (first month after)

Was your sleep affected (first month after)

44.1) How was your sleep affected?

How was your sleep affected?

Pain

Other

44.1) i) Client's sleep affected in other ways:

Further details of other ways your sleep was affected:

Did you visit your GP over the next 6 months for:

45) Any emotional reason (to do with the incident)

Any emotional reason (to do with the incident)

45.1) Approximate date: emotional reason

Approximate date: emotional reason

45) a) Details of emotional reason

Details of emotional reason

46) Were you given medication for this?

Were you given medication for this?

46.1) Approximate date: given medication

Approximate date: given medication

46) a) Details of medication

Details of medication

47) After the accident, were you referred to see a counsellor, psychologist or psychiatrist

After the accident, were you referred to see a counsellor, psychologist or psychiatrist

47.1) Approximate date: referral to counsellor/psychologist/psychiatrist

Approximate date: referral to counsellor/psychologist/psychiatrist

47) a) Details of support received (e.g. psychological treatment, crisis team, home treatment, inpatient stay, CMHN or medication review)

Details of support received (e.g. psychological treatment, crisis team, home treatment, inpatient stay, CMHN or medication review)

48) Date and details of discharge/number of sessionsist/psychiatrist

Date and details of discharge/number of sessions

After the Accident

48) a) Were you involved in a vehicle accident as an occupant?

Were you involved in a vehicle accident as an occupant?

49) Was the car written off?

Was the car written off?

Not Applicable

49.1) Additional details of car being written off

Additional details of car being written off

50) Did you get another car after the accident (e.g. courtesy car, hire car, other family car etc.)?

Did you get another car after the accident (e.g. courtesy car, hire car, other family car etc.)?

Not Applicable

50.1) Additional details of courtesy car, hire car, other family car etc.

Additional details of courtesy car, hire car, other family car etc.

51) Did you drive the courtesy car, hire car, other family car etc?

Did you drive the courtesy car, hire car, other family car etc?

Not Applicable

51.1) How often did you drive the courtesy car, hire car, other family car etc.

How often did you drive the courtesy car, hire car, other family car etc.

52) When was the car repaired and returned?

When was the car repaired and returned?

53) When was the car (if written off) replaced?

When was the car (if written off) replaced?

54) Have you been involved in any further similar incidents since the incident in question?

Have you been involved in any further similar incidents since the incident in question?

54.1) Please give further details of these subsequent incidents (e.g. date and description)

Please give further details of these subsequent incidents (e.g. date and description)

55) Do you have any emotional problems due to the incident now?

Do you have any emotional problems due to the incident now?

55.1) Details of emotional problems

Details of emotional problems

Did any of the following events affect you?

56.1) Other driver's difficult attitude

Other driver's difficult attitude

Not Applicable

56.1) a) Details of other driver's difficult attitude

Details of other driver's difficult attitude

56.2) Dealing with the litigation

Dealing with the litigation

56.2) a) Details of dealing with the litigation

Details of dealing with the litigation

56.3) Your employer's difficult attitude

Your employer's difficult attitude

Not Applicable

56.3) a) Details of employer's difficult attitude

Details of employer's difficult attitude

57) a) In the past month how many times have you driven each week (approximately)?

In the past month how many times have you driven each week (approximately)?

57) b) How many times have you been a passenger each week (approximately)?n each week (approximately)?

How many times have you been a passenger each week (approximately)?

58) Do you think you need any psychological treatment now?

Do you think you need any psychological treatment now?

58.1) What do you need treatment for?

What do you need treatment for?

59) How would you rate your pain currently between 0 (no pain) and 10 (unbearable)?

How would you rate your pain currently between 0 (no pain) and 10 (unbearable)?

0	1	2	3	4	5	6	7	8	9	10

60) Do you currently do any of the following?

Do you currently do any of the following?

Housework

Socialising

Hobbies outside the house

Exercise

Shopping

60.1) Do you need help with any daily activities (e.g. chores, cooking, personal care)?

Do you need help with any daily activities (e.g. chores, cooking, personal care)?

60.1 a) Please give details

Please give details

61) Have any of the following stressful life events occurred since the incident?

Have any of the following stressful life events occurred since the incident?

61.1) Stressful life events checklist - 12 months AFTER incident

Stressful life events checklist - 12 months AFTER incident

Work Accident (and injury)

Redundancy

Fear of Redundancy

Work Harassment or stress

Disciplinary Situation

Car Accident

Motorbike Accident

Cycle Accident

Pedestrian Accident

Significant Medical Illness

Hospital Stay

Medical Accident

Childbirth

Termination

House Move

Alcohol Misuse

Non-Prescribed Drug Use

Antidepressant Medication

Significant Financial Debts

Marriage

Divorce

Relationship problems or Separation

Neighbour Dispute

Bereavement or Serious Illness to Close Relatives / close friend

Problems with your children

61.1 a) Details of problems with your children AFTER incident

Details of problems with your children AFTER incident

61.1) b) Stressful life events checklist - 12 months AFTER incident

Stressful life events checklist - 12 months AFTER incident

Other

61.1) b) i) Details of other stressful life events - 12 months after incident:

Please give details

62) Was liability disputed?

Was liability disputed?

62.1)When was this settled (or is it ongoing)?

When was this settled (or is it ongoing)?

Consent(Required)

I have answered all these questions truthfully, to the best of my knowledge