PIAB Irish Medicolegal Template 1

PIAB Medical Assessment Form (Form B) PIAB Application Number [PIAB application number] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Examining Doctor's Name [Full name and title of examining doctor] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line. Do not invent or infer a clinician name.) Claimant Name [Claimant's full name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Address [Claimant's full address including street, city, and postcode] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Gender [Claimant's gender] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Date of Birth [Claimant's date of birth in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Occupation (including details of any change since the date of accident) [Claimant's occupation and any changes to it since the accident date] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Currently at work? 1. [ ] [Mark with X if claimant is currently at work] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Yes" 2. [ ] [Mark with X if claimant is not currently at work] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "No" Right or left hand dominant? 1. [ ] [Mark with X if claimant is right hand dominant] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Right" 2. [ ] [Mark with X if claimant is left hand dominant] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Left" Height [Claimant's height in cm or metres] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Weight [Claimant's weight in kg] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) BMI (and details of any change since accident date) [Claimant's BMI and any changes since the accident date] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Date of Accident [Date of accident in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Examination Date [Date of examination in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Total Time Elapsed Since Date of Accident (date of accident to examination date) Years: [Number of years elapsed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Months: [Number of months elapsed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Brief Accident Details [Brief description of the accident details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Details of Dominant/Most Significant Injury Sustained (within your expertise) (Include history of condition immediately after accident and in subsequent few days) [Description of the dominant or most significant injury sustained, including its history immediately after the accident and in the subsequent few days, within the examining doctor's expertise] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Details of Other Injuries Sustained (Include history of condition immediately after accident and in subsequent few days) [Description of any other injuries sustained, including their history immediately after the accident and in the subsequent few days] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Date First Treatment Sought [Date first treatment was sought in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) From Who Was It Received? [Name and role of person or service who provided first treatment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line. Do not invent or infer a clinician name.) Was Claimant Hospitalised? 1. [ ] [Mark with X if claimant was hospitalised] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Yes" 2. [ ] [Mark with X if claimant was not hospitalised] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "No" If hospitalised, where? [Location of hospitalisation if the claimant was hospitalised] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Duration of Inpatient Stay [Duration of inpatient stay in days or weeks] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Total Length of Absence from Work Years: [Number of years absent from work] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Months: [Number of months absent from work] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) From: [Start date of absence from work in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) To: [End date of absence from work in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) If Absence is Ongoing, Is It Due to the Accident? [Statement on whether ongoing absence from work is due to the accident] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Was/Is the Claimant's Absence Period Reasonable? 1. [ ] [Mark with X if the claimant's absence period was or is considered reasonable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Yes" 2. [ ] [Mark with X if the claimant's absence period was or is not considered reasonable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "No" Number of GP Visits [Total number of GP visits] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Number of Specialist/Consultant Visits [Total number of specialist or consultant visits] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Identity of Specialist/Consultant(s), if Known [Names and specialities of specialist(s) or consultant(s) if known] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line. Do not invent or infer clinician names.) Treatment and Investigations to Date (Type and name of investigations and results if available, including information regarding medications, dosage, and changes since the accident or in the last six months) [All treatments and investigations received to date including types, names, available results, medications, dosages, and changes since the accident or in the last six months] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Number of Physiotherapy Sessions, if Any [Number of physiotherapy sessions if any] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) X-Ray/MRI Results [X-Ray or MRI results including commentary on whether findings are age-related, whether the claimant would likely have experienced symptoms regardless of the accident, and whether symptoms aggravated by the accident will return to a pre-accident state and if so when] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) World Health Organisation (WHO) International Classification of Diseases (ICD) [Dominant injury ICD code or multiple codes if applicable] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Relevant Medical History Relevant History? 1. [ ] [Mark with X if there is relevant medical history] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Yes" 2. [ ] [Mark with X if there is no relevant medical history] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "No" Aggravation of Pre-Existing Condition? 1. [ ] [Mark with X if there was aggravation of a pre-existing condition] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Yes" 2. [ ] [Mark with X if there was no aggravation of a pre-existing condition] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "No" If Yes, Please Give Nature of Pre-Existing Condition [Nature of the pre-existing condition if applicable] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Give Details of Previous (or Subsequent) Accident History, if Any [Details of any previous or subsequent accident history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Was Pre-Existing Condition Active/Symptomatic Before the Accident? [Statement on whether the pre-existing condition was active or symptomatic before the accident] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Present Complaints to Include Effects on Lifestyle/Recreational and Domestic Personal Activities [Claimant's present complaints including their effects on lifestyle, recreational, and domestic personal activities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Impact on Employment [Impact of the complaints on the claimant's employment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Interference with Quality of Life and Leisure Activities [Interference with the claimant's quality of life and leisure activities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Impact on Personal Relationships [Impact of the complaints on the claimant's personal relationships] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Visual Analogue Scale (VAS) for Pain Score [Visual Analogue Scale pain score out of 10] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Clinical Findings on Examination [Clinical findings on examination including range of movements and note of whether photographs of accident-related scarring are included] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Clinical Description of Effects of Claimant's Illness/Accident/Disablement Mental Health 1. [ ] [Mark with X if mental health is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if mental health is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if mental health is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if mental health is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if mental health is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Learning/Intelligence 1. [ ] [Mark with X if learning/intelligence is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if learning/intelligence is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if learning/intelligence is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if learning/intelligence is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if learning/intelligence is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Consciousness/Seizure 1. [ ] [Mark with X if consciousness/seizure is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if consciousness/seizure is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if consciousness/seizure is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if consciousness/seizure is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if consciousness/seizure is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Balance/Co-ordination 1. [ ] [Mark with X if balance/co-ordination is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if balance/co-ordination is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if balance/co-ordination is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if balance/co-ordination is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if balance/co-ordination is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Vision 1. [ ] [Mark with X if vision is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if vision is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if vision is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if vision is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if vision is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Hearing 1. [ ] [Mark with X if hearing is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if hearing is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if hearing is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if hearing is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if hearing is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Speech 1. [ ] [Mark with X if speech is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if speech is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if speech is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if speech is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if speech is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Continence 1. [ ] [Mark with X if continence is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if continence is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if continence is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if continence is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if continence is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Reaching 1. [ ] [Mark with X if reaching is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if reaching is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if reaching is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if reaching is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if reaching is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Manual Dexterity 1. [ ] [Mark with X if manual dexterity is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if manual dexterity is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if manual dexterity is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if manual dexterity is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if manual dexterity is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Carrying/Lifting 1. [ ] [Mark with X if carrying/lifting is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if carrying/lifting is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if carrying/lifting is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if carrying/lifting is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if carrying/lifting is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Bending/Stooping 1. [ ] [Mark with X if bending/stooping is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if bending/stooping is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if bending/stooping is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if bending/stooping is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if bending/stooping is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Sitting 1. [ ] [Mark with X if sitting is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if sitting is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if sitting is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if sitting is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if sitting is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Standing 1. [ ] [Mark with X if standing is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if standing is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if standing is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if standing is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if standing is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Climbing Stairs 1. [ ] [Mark with X if climbing stairs is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if climbing stairs is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if climbing stairs is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if climbing stairs is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if climbing stairs is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Walking 1. [ ] [Mark with X if walking is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if walking is Minor] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Minor" 3. [ ] [Mark with X if walking is Moderate] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Moderate" 4. [ ] [Mark with X if walking is Serious] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Serious" 5. [ ] [Mark with X if walking is Severe] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Severe" Opinion/General Comments and Latest Prognosis Indicate the degree to which you feel all of the claimant's symptoms/disability have been caused by the accident/event which is the subject of this claim; based on assessment of the injury as described by the claimant, the accident/events accounts for: 1. [ ] [Mark with X if none of the symptoms/disability are caused by the accident] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "None of the symptoms/disability" 2. [ ] [Mark with X if a small proportion (≤25%) of symptoms/disability are caused by the accident] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "A small proportion (≤25%) of the symptoms/disability" 3. [ ] [Mark with X if a moderate proportion (50%) of symptoms/disability are caused by the accident] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "A moderate proportion (50%) of the symptoms/disability" 4. [ ] [Mark with X if most (≥75%) of symptoms/disability are caused by the accident] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Most (≥75%) of the symptoms/disability" 5. [ ] [Mark with X if all of the symptoms/disability are caused by the accident] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "All of the symptoms/disability" Please Comment Further [Further comments regarding the causation of symptoms or disability] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Are Further Investigations Required in Respect of Any of the Injuries Sustained in the Accident? 1. [ ] [Mark with X if further investigations are required] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Yes" 2. [ ] [Mark with X if further investigations are not required] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "No" Details of Further Investigations Required [Details of any further investigations required] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Is the Medical Intervention and Treatment Received Consistent with the Injuries Suffered? 1. [ ] [Mark with X if medical intervention and treatment are consistent with injuries suffered] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Yes" 2. [ ] [Mark with X if medical intervention and treatment are not consistent with injuries suffered] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "No" If Not Consistent, Please Comment Further [Further comments if medical intervention and treatment are not consistent with injuries suffered] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) If a Claimant Has a Pre-Existing Condition That Is Aggravated by an Injury, Please Detail the Extent to Which the Pre-Existing Injury Has Been Made Worse and the Duration of Any Increased Symptomology [Detail of the extent to which a pre-existing injury has worsened and the duration of any increased symptomology] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Estimated Total Time Period from the Date of Accident in Which a Substantial Recovery Took Place Years: [Number of years for substantial recovery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Months: [Number of months for substantial recovery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) If a Substantial Recovery Has Not Already Taken Place, Please Provide the Estimated Total Time Period from the Date of Accident to Substantial Recovery Years: [Estimated number of years to substantial recovery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Months: [Estimated number of months to substantial recovery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Are Late Complications Expected? 1. [ ] [Mark with X if late complications are expected] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Yes" 2. [ ] [Mark with X if late complications are not expected] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "No" If a Substantial Recovery Is Not Expected, Please Detail the Expected Prognosis Including the Likely Effects on Lifestyle/Work [Expected prognosis including likely effects on lifestyle and work if substantial recovery is not expected] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Are Further Specialist Reports Recommended? 1. [ ] [Mark with X if further specialist reports are recommended] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Yes" 2. [ ] [Mark with X if further specialist reports are not recommended] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "No" If Further Specialist Reports Are Recommended, Please Specify the Speciality Required [Speciality required if further specialist reports are recommended] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Anticipated Future Treatment Required (Include approximate future treatment costs if applicable) [Anticipated future treatment required including approximate future treatment costs if applicable] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Summary/Additional Information [Summary or any additional information] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Completed By (It is the duty of the completing expert to assist as to matters within his or her field of expertise. This duty overrides any obligation to any party paying the fee of the expert.) Name [Full name and title of completing expert] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line. Do not invent or infer a clinician name.) Signature [Signature of completing expert] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Address [Address of completing expert] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Qualifications [Qualifications of completing expert] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Medical Council Registration Number [Medical council registration number of completing expert] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Completion Date [Completion date of the form in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Please Complete This Section Only if a Claimant Has Suffered Neck Pain or Whiplash Associated Disorder (WAD) (Findings as at time of examination) [Findings related to neck pain or Whiplash Associated Disorder as at the time of examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Assessment of Cervical Range of Motion 1. [ ] [Mark with X if cervical range of motion is Normal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Normal" 2. [ ] [Mark with X if cervical range of motion is Abnormal] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Abnormal" Palpation for Consistent Tenderness 1. [ ] [Mark with X if consistent tenderness is Present] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Present" 2. [ ] [Mark with X if consistent tenderness is Absent] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Absent" Neurological Signs 1. [ ] [Mark with X if neurological signs are Present] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Present" 2. [ ] [Mark with X if neurological signs are Absent] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Absent" Indicate the Whiplash Associated Disorder (WAD) Grade (Following assessment, claimants should be classified according to the Quebec Task Force (QTF) Classification of Grades) 1. [ ] [Mark with X if WAD Grade is 0] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "WAD 0 — No neck pain, stiffness or any physical signs are noticed" 2. [ ] [Mark with X if WAD Grade is I] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "WAD I — Complaints of neck pain, stiffness, but no physical signs" 3. [ ] [Mark with X if WAD Grade is II] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "WAD II — Neck complaints and decreased range of motion and local tenderness in the neck" 4. [ ] [Mark with X if WAD Grade is III] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "WAD III — Neck complaints and neurological signs" 5. [ ] [Mark with X if WAD Grade is IV] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "WAD IV — Neck complaints and fracture, dislocation or injury to the spinal cord" If the Claimant's WAD Grade Has Changed During the Course of Their Recovery, Please Comment on These Changes [Comments on any changes in the claimant's WAD Grade during recovery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Neck Disability Index (NDI) Score [NDI percentage score] % (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) (Neck Disability Index (NDI) and Visual Analogue Scale (VAS) questionnaires are to be completed by claimants. Calculation of NDI scoring is completed by medical practitioners — there are 10 individual sections each with a maximum score of 5. Each section has 6 statements. A single most appropriate statement of the 6 options is chosen for each section. The options are scored in ascending order from 0–5. Example: 16 = total scored for all sections of a possible 50 — 16/50 x 100 = NDI 32%. If a section is missed or not applicable, the score is calculated on the basis of sections answered e.g. 16/45 x 100 = NDI 35.5%.) Neck Disability Index (NDI) (To be completed by claimant where there is a neck injury or pain) Claimant Name [Claimant's name for the NDI questionnaire] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) PIAB Reference [PIAB reference for the NDI questionnaire] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Date Completed [Date the NDI questionnaire was completed in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) This questionnaire has been designed to provide information as to how your neck pain has affected your ability to manage in everyday life. Please mark in each and every section (1–10) only one box that applies to you. We realise you may consider that two or more statements in any one section relate to you, but please mark just the box in each section that most closely describes your problem. Section 1: Pain Intensity 1. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I have no pain at the moment" 2. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "The pain is very mild at the moment" 3. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "The pain is moderate at the moment" 4. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "The pain is fairly severe at the moment" 5. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "The pain is very severe at the moment" 6. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "The pain is the worst imaginable at the moment" Section 2: Personal Care (washing, dressing, etc.) 1. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can look after myself normally without causing extra pain" 2. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can look after myself normally but it causes extra pain" 3. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "It is painful to look after myself and I am slow and careful" 4. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I need some help but can manage most of my personal care" 5. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I need help every day in most aspects of self-care" 6. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I do not get dressed, I wash with difficulty and stay in bed" Section 3: Lifting 1. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can lift heavy weights without extra pain" 2. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can lift heavy weights but it gives extra pain" 3. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed, for example on a table" 4. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned" 5. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can only lift very light weights" 6. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I cannot lift or carry anything" Section 4: Reading 1. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can read as much as I want to with no pain in my neck" 2. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can read as much as I want to with slight pain in my neck" 3. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can read as much as I want to with moderate pain in my neck" 4. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I cannot read as much as I want to because of moderate pain in my neck" 5. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can hardly read at all because of severe pain in my neck" 6. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I cannot read at all" Section 5: Headaches 1. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I have no headaches at all" 2. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I have slight headaches, which occur infrequently" 3. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I have moderate headaches, which come infrequently" 4. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I have moderate headaches, which come frequently" 5. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I have severe headaches, which come frequently" 6. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I have headaches almost all the time" Section 6: Concentration 1. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can concentrate fully when I want to with no difficulty" 2. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can concentrate fully when I want to with slight difficulty" 3. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I have a fair degree of difficulty in concentrating when I want to" 4. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I have a lot of difficulty in concentrating when I want to" 5. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I have a great deal of difficulty in concentrating when I want to" 6. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I cannot concentrate at all" Section 7: Work 1. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can do as much work as I want to" 2. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can only do my usual work, but no more" 3. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can do most of my usual work, but no more" 4. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I cannot do my usual work" 5. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can hardly do any work at all" 6. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I cannot do any work at all" Section 8: Driving 1. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can drive my car without any neck pain" 2. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can drive my car as long as I want with slight pain in my neck" 3. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can drive my car as long as I want with moderate pain in my neck" 4. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I cannot drive my car as long as I want because of moderate pain in my neck" 5. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can hardly drive at all because of severe pain in my neck" 6. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I cannot drive my car at all" Section 9: Sleeping 1. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I have no trouble sleeping" 2. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "My sleep is slightly disturbed (less than 1 hr sleepless)" 3. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "My sleep is mildly disturbed (1–2 hrs sleepless)" 4. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "My sleep is moderately disturbed (2–3 hrs sleepless)" 5. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "My sleep is greatly disturbed (3–5 hrs sleepless)" 6. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "My sleep is completely disturbed (5–7 hrs sleepless)" Section 10: Recreation 1. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I am able to engage in all my recreation activities with no neck pain at all" 2. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I am able to engage in all my recreation activities, with some pain in my neck" 3. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I am able to engage in most, but not all, of my usual recreation activities because of pain in my neck" 4. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I am able to engage in a few of my usual recreation activities because of pain in my neck" 5. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I can hardly do any recreation activities because of pain in my neck" 6. [ ] [Mark with X if applicable] (Only mark with X if explicitly mentioned in transcript, context or clinical note, else leave as [ ]. Do not omit the checkbox even if no information is mentioned.) "I cannot do any recreation activities at all" Claimant Signature: [Claimant's signature] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Date: [Date of signature in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Visual Analogue Scale (VAS) for Pain (To be completed by claimant) Claimant Name [Claimant's name for the VAS questionnaire] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) PIAB Reference [PIAB reference for the VAS questionnaire] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Date of Assessment [Date of the VAS assessment in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) "The VAS for pain consists of a 10cm line with two end-points representing 'no pain' and 'pain as bad as it could possibly be'. Claimants are asked to rate their pain by placing a mark on the line corresponding to their current level of pain. The distance along the line from the 'no pain' marker can then be measured giving a pain score out of 10." [Claimant's pain rating on the VAS scale as a score out of 10] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Claimant Signature: [Claimant's signature for VAS] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Date: [Date of VAS signature in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)