Medical Incident Questionnaire Please give detailed information as this will be helpful for your assessment interview. 1Demographics2BEFORE the incident in question3The Incident / Episode 4After the Incident / Episode DemographicsYour Name(Required) First Last Your E-mail(Required) Enter Email Confirm Email Your Date of Birth(Required) DD slash MM slash YYYY Your AgeYour Marital Status(Required) Date of incident(Required) DD slash MM slash YYYY Type of incident(Required) Where do you live now?(Required) Do you have any children?(Required) Details of your children (Sex and age)(Required)Do you have any brothers or sisters?(Required) Details of your brothers and sisters(Required)Where did you grow up?(Required) Briefly describe your childhood years(Required)How old were you when you left school or education and what was your highest level of qualification?(Required) What other qualifications do you have or what trades have you trained in?(Required) What was your job at the time of the incident?(Required) Was that full time / part time / permanent / Agency / zero hours? How long had you been doing this job for at the time of the incident?(Required) BEFORE the incident in questionHave you ever experienced any previous similar or significant incidents BEFORE the incident in question?(Required) Please give dates and details Did these experiences, before the incident in question, leave you with any psychological problems? For how long? Have you ever experienced any psychological or psychiatric problems that you have need to seek help for?(Required) Was the episode brought about by any particular event(s)? Please give details below.When was this and how long did it last? What treatment/s were you given? e.g. antidepressants / psychological treatment / counselling / anything else? Was this treatment ongoing just before the incident? Have you ever experienced any difficult or significantly stressful events in your life?(Required)Examples might be, bereavement, family difficulties illness (self or family), relationship breakdown with child contact issues, problems with the police etc. Details of significantly stressful events:Is there any psychiatric history in immediate family members?(Required) Details of psychiatric history:Have you ever been convicted of a criminal offence as an adult?(Required) Details of convictions:Have you ever had any previous personal injury claims?(Required) Please give brief details (when they occurred, what they were about).Have you ever consumed drugs or alcohol to the extent that it might be considered problematic?(Required) Please give brief details of consumption:Had you ever had any significant periods of time off work in the year prior to this incident?(Required) Please give brief details of time off work:In a sentence, please describe how life in general, was for you in the weeks leading up to this episode?(Required) The Incident / EpisodePlease describe what happened to you.(Required)Were you given an explanation about how this came to happen?(Required) Please give details. After the Incident / EpisodePlease describe how this left you feeling, emotionally.(Required)Did these / this improve over time?(Required) How long were these problems at their worst for? Have you been offered treatment in the form of therapy or medication?(Required) Please give details, including dates.How have you coped with this over time / what has helped?Do you still have psychological problems now?(Required) What are these now (continuing over the past 2-4 weeks)?What do you think keeps these psychological difficulties going on a day-to-day basis now?Do you think you need psychological help now to overcome the remaining issues?Have you experienced any additional, difficult events since this happened, that have been difficult to cope with?(Required) Please give details and dates.What do you think has been the impact of the litigation process on you?Have you or immediate family members needed to seek medical treatment?(Required) What has this experience been like for you?Is there anything else you would like to add, that you think the assessing psychologist should be made aware of?Consent(Required) I have answered all these questions truthfully, to the best of my knowledgeEmailThis field is for validation purposes and should be left unchanged.
