PIAB Irish Medicolegal Template 2

IDENTIFICATION Patient Name: [Patient's full name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) PIAB Reference / Application Number: [Patient's PIAB reference or application number] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Examining Doctor: [Examining doctor's full name and title] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text. Do not invent or infer a clinician name.) Date of Birth: [Patient'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 plain text.) Gender: [Patient's gender: Male / Female / Other] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Address: [Patient'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 plain text.) Occupation (include changes since accident): [Patient's occupation and any changes since the accident] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Currently at Work: 1. [ ] [Mark with X if patient 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 patient 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" Dominant Hand: 1. [ ] [Mark with X if patient 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 patient 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: [Patient's height in cm] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Weight: [Patient's weight in kg] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) BMI (and change since accident): [Patient's BMI and description of any change since the accident] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) INCIDENT 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 plain text.) 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 plain text.) Total Time Elapsed Since Accident: [Number of years] years [Number of months] months (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Brief Accident Details: [Description of how the accident occurred and immediate events, focusing on details relevant to medical injuries and mechanism of injury] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) DOMINANT / MOST SIGNIFICANT INJURY Details of Dominant/Most Significant Injury (include history immediately after accident and subsequent days): [Main injury identified, specifying the body region and clinical problem] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) [History of symptom onset, character, and progression for the dominant injury] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) OTHER INJURIES Details of Other Injuries Sustained (history immediate and subsequent few days): [List of other injuries sustained with a short history for each] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list, each item on a new line.) INITIAL CARE & HOSPITALISATION Date First Treatment Sought: [Date in DD/MM/YYYY format when first treatment was sought] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) From Whom: [Source of first treatment including role and name if known] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text. 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 Yes — Where: [Name of hospital if claimant was hospitalised] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Duration of Inpatient Stay: [Duration of inpatient stay in days] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Total Length of Absence from Work: From [Start date of absence in DD/MM/YYYY format] to [End date of absence in DD/MM/YYYY format, or state "ongoing" if still absent] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) If Ongoing, Is Absence Due to the Accident: 1. [ ] [Mark with X if ongoing absence is due to 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.) "Yes" 2. [ ] [Mark with X if ongoing absence is not due to 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.) "No" Was the Absence Reasonable: 1. [ ] [Mark with X if the absence period was 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 absence period was 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 plain text.) 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 plain text.) Specialist(s) Identity (if known): [Names and specialties of involved specialists] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list, each item on a new line. Do not invent or infer clinician names.) TREATMENT & INVESTIGATIONS TO DATE Medications (name, dose, start/stop/change since accident): [List of medications, dosages, and any changes since the accident] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list, each item on a new line.) Physiotherapy Sessions: [Total number of physiotherapy sessions and summary of patient's response to treatment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Imaging and Test Results (X-ray/MRI/CT/bloods): [Name of each test, date performed, and key result or clinical interpretation, including whether imaging suggests age-related change or pre-existing abnormality and its likely activation or aggravation by the accident] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list, each item on a new line.) Other Treatments (injections, surgery, psychological therapy): [List of other treatments received including dates] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list, each item on a new 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" If Yes — Describe: [Past medical conditions relevant to the current claim] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) 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 — Nature of Pre-Existing Condition: [Description of the nature of the pre-existing condition] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Was Pre-Existing Condition Active/Symptomatic Before the Accident: 1. [ ] [Mark with X if pre-existing condition was active or symptomatic before 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.) "Yes" 2. [ ] [Mark with X if pre-existing condition was not active or symptomatic before 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.) "No" 3. [ ] [Mark with X if it is unknown whether pre-existing condition was active or symptomatic before 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.) "Unknown" Previous (or Subsequent) Accidents (dates and brief details): [List of previous or subsequent accidents including dates and brief details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list, each item on a new line.) PRESENTING COMPLAINTS & EFFECTS Presenting Complaints (symptoms, severity, temporal pattern): [Description of current symptoms, severity, and temporal pattern] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Impact on Lifestyle / Recreational / Domestic Activities: [Description of specific limitations on lifestyle, recreational, and domestic activities due to the injury] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Impact on Employment (tasks affected, hours, modifications): [Description of impact on employment including affected tasks, hours, and any modifications made] (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: [Description of how the injury interferes with 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: [Description of impact on personal relationships due to the injury] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) PAIN & FUNCTIONAL SCORES Visual Analogue Scale (current pain): [Patient's current pain score out of 10] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Neck Disability Index (NDI) Score (if neck injury): [NDI score as a percentage] % (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) CLINICAL EXAMINATION & FINDINGS Vital Signs at Exam (if relevant): [Patient's blood pressure, heart rate, and temperature at time of examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) General Appearance: [Description of patient's general appearance e.g. distressed, comfortable, antalgic posture] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Local Examination (per region): Head / Neck: [Findings related to range of motion, tenderness, and neurological signs in the head and neck region] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Thorax / Chest: [Findings from examination of the thorax and chest] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Lumbar / Back: [Findings related to range of motion, tenderness, and neural signs in the lumbar and back regions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Upper Limb: [Findings related to strength, reflexes, sensation, and range of motion in the upper limbs] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Lower Limb: [Findings related to strength, reflexes, sensation, and gait in the lower limbs] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Range of Motion — Documented: [Specific measurements of range of motion e.g. cervical flexion xx°, extension xx°] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list, each item on a new line.) Neurological Examination: [Description of any neurological deficits found during examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Special Tests Performed and Results: [Name of special tests performed and their results] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list, each item on a new line.) Photographs of Scarring (if relevant): [Note whether photographs of accident-related scarring are included] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) FUNCTIONAL IMPACT RATING Clinical description of effects on ability — mark the most appropriate level for each domain: Normal / Minor / Moderate / Serious / Severe 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, CAUSATION & PROGNOSIS Opinion / General Comments and Latest Prognosis: [Free-text summary of clinical course, current status, and latest prognosis] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Degree to Which Claimant's Symptoms/Disability Are Caused by the Accident: 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" [Short explanation of reasoning and evidence for causation opinion] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Are Further Investigations Required: 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: [List of tests required and their rationale] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list, each item on a new line.) Is the Medical Intervention Received Consistent with the Injuries: 1. [ ] [Mark with X if medical intervention is consistent with injuries] (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 is not consistent with injuries] (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, Comment: [Explanation of any discrepancy if medical intervention is not consistent with injuries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) If Pre-Existing Condition Aggravated — Extent and Duration of Increased Symptomology: [Description of the extent and duration of increased symptomology if a pre-existing condition was aggravated] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Estimated Period to Substantial Recovery (from date of accident): [Estimated years and months to substantial recovery from date of accident] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) If Not Yet Recovered — Estimated Time to Substantial Recovery: [Estimated years and months to substantial recovery from current date] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) 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 Yes — Describe: [Description of expected late complications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) If Substantial Recovery Not Expected — Detail Expected Prognosis Including Likely Effects on Lifestyle/Work: [Detailed expected prognosis including likely effects on lifestyle and work] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) FURTHER SPECIALIST REPORTS & FUTURE TREATMENT 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 Yes — Speciality Required: [Required specialty e.g. Orthopaedics, Neurosurgery, Psychiatry, Pain Medicine, Rheumatology] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Anticipated Future Treatment Required (including approximate future treatment costs if applicable): [Description of anticipated future treatment and approximate 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 [One-paragraph summary of the dominant injury, treatment to date, functional impact, causation opinion, prognosis, and recommended next steps] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph of full sentences.) COMPLETION & SIGNATURE Completed By: [Full name and title of clinician completing the report] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text. Do not invent or infer a clinician name.) Qualifications: [Qualifications of the clinician] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Medical Council Registration Number: [Medical Council registration number of the clinician] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Address (Clinician): [Address of the clinician's clinic or hospital] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Completion Date: [Date of completion in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) Signature: [Clinician signature line] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as plain text.) PIAB WAD SECTION (Only complete when neck pain or whiplash is applicable) 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" WAD Grade: 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" 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 plain text.) [Changes in WAD grade over time if relevant, and NDI questionnaire results completed by claimant] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) (Never include patient details, assessments, plans, interventions, evaluations, or plans for continuing care that have not been explicitly mentioned in the transcript, contextual notes, or clinical note. Do not state in your output that information has not been mentioned — simply omit the relevant section entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)