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General Web Page/Brochure
If you suffered an accident you should normally recover. However it can be worrying thinking you may not.
Some claims for compensation can seem to take ages and you may feel you need help now.
We can help predict if your injury will recover as expected or suffer a more prolonged course. This will put you in the best position to assess what you need to do to regain your health and wealth.
You may have decided to get independent expert advice if you have been offered a settlement for compensation. You may have been asked by your solicitor to decide if the injuries that you sustained in an accident need early therapy.
Questionnaire
Name title: Mr Mrs Ms Dr other
Date of Birth
Address
Post code capture: if you know your postcode please type it here & we will attempt to fetch up your address.
Email
Telephone No
Date of questionnaire (Autofill)
Claim Criteria
 
A. Was some one else wholly (or partially) responsible for the accident
  Y N 
B. Did the accident/event take place in England or Wales?
 Y N 
C. They have suffered Injuries (physical or psychological) as result of the accident
Y N 
D. When was the accident?
Date --/--/--
 RESPONSES:
(If answered No to any of questions A-C) Please phone helpline on 0845??????.
(if more than 3 yr ago ) Are you sure the accident was more than 3years ago. If later please retype date otherwise please phone helpline on 0845??????.
If none of the above
Your login name is = forename. surname
Please choose a password ******
Please retype password ******
Password hint text
Welcome forenam.surname
Questionnaire - MLDI
If you suffered an accident you should normally recover. However it can be worrying thinking you may not. We can help predict if your injury will recover as expected or suffer a prolonged course.
This questionnaire will help us help you decide what to do next.
The answers are confidential and will help guide any early therapy you may need.
Please take time to fill in the questions. The questions either require a simple yes or no or they may require a score out of 10.
Here is an example of the type of questions you will be asked
A. I like apples. (Please circle one)
0 1 2 3 4 5 6 7 8 9 10
Not at all Very much
If you really like apples you would click on number 10, if you really hate apples you could click 0.
Please complete the triage questionnaire
 
 
 
1. What type of accident was it?
 
Motor Vehicle Accident
 
Slipped & / or Tripped
 
Medical Negligence
 
Other
 
 
 
2. Did it happen when you were working?
 
Y N 
 
 
 
 
 
3. Do you think you will need help to recover?
 
Y N
 
 
 
4. What part(s) of the body did you injure?
 
 
Head
 
Neck
 
Shoulder and arm
 
Hand and wrist
 
Back
 
Chest
 
Pelvis /abdomen
 
Hip , knee or Leg
 
Ankle
 
Other
 
 
 
5. Did you have an existing problem with the area that was injured or near that area?
 
Y N
 
 
 
6. What would best describe the problem you have after the accident?
 
Whiplash.
 
You may be suffering from more han one problem. If so please tick more than one box.
 
Whiplash
 
Muscle & bone problem
 
Psychological problem
 
Not sure
 
Other
 
 
 
 
 
7. What do you think the severity of the injury was/is?
 
0 1 2 3 4 5 6 7 8 9 10
 
No Total
 
Disability Disability   
 
 
 
8. How much pain did you experience in first 4 days after the accident/ event?
 
0 1 2 3 4 5 6 7 8 9 10
 
No pain the worst pain
 
I can imagine
 
 
 
9. How much pain are you in now?
 
0 1 2 3 4 5 6 7 8 9 10
 
No pain the worst pain
 
I can imagine
 
 
 
 
 
10. How many times have you seen a health professional after the accident?
 
 
0 1 2 3 4 5 6 7 8 9 10
 
This part of the questionnaire has been designed to give information as to how your pain and disability has affected your ability to manage everyday life.
 
Please answer every section and mark the number on the scale that describes the level of disability you usually experience.
 
A score of 0 means no disability and a score of 10 means all activities in that area are totally disrupted.
 
Respond to each section by indicating the overall impact of your pain and disability not just when its at its worse.
 
 
 
 
11. Do you have problems with Personal care?
 
Y N 
 
How would you rate this on a scale where 0 is none & 10 the most.
 
This would include getting dressed or taking a shower etc.
 
0 1 2 3 4 5 6 7 8 9 10
 
No Total
 
Disability Disability
 
I do not get dressed;
 
I wash with difficulty and stay in bed.
 
 
 
12. Can you carry out domestic duties?
 
Y N 
 
How would you rate this on a scale where 0 is none & 10 the most.
 
This includes activities around the home
 
0 1 2 3 4 5 6 7 8 9 10
 
No problem. Totally unable to carry out any domestic tasks
 
 
 
13. Has your work been affected?
 
Y N
 
 
 
How would you rate this on a scale where 0 is none & 10 the most.
 
0 1 2 3 4 5 6 7 8 9 10
 
No Total
 
Disability Disability
 
 
 
14. Has your travel been affected?
 
Y N 
 
How would you rate this on a scale where 0 is none & 10 the most.
 
This include driving been driven in a care, travelling on public transport.
 
0 1 2 3 4 5 6 7 8 9 10
 
I can drive/ travel as usual. I cannot drive or travel at all
 
 
 
15. Has you sleep been affected?
 
Y N 
 
How would you rate this on a scale where 0 is none & 10 the most.
 
This would mean any disruption of your normal sleep pattern e.g. completely disrupted night sleep
 
0 1 2 3 4 5 6 7 8 9 10
 
No Total
 
Disability Disability
 
I have no trouble sleeping. My sleep is completely disturbed .
 
 
 
16. Do you suffer mood problems now?
 
Y N 
 
How would you rate this on a scale where 0 is none & 10 the most.
 
This would include your enjoyment of life.
 
0 1 2 3 4 5 6 7 8 9 10
 
Normal Mood I don’t enjoy anything
 
I still enjoy the things I use to enjoy I do not enjoy the things I use to enjoy
 
Did you suffer any mood problems before the accident?
 
Y N 
 
 
 
17. Has your recreation been affected?
 
Y N
 
 
 
How would you rate this on a scale where 0 is none & 10 the most.
 
This includes hobbies, sports and other leisure activities.
 
0 1 2 3 4 5 6 7 8 9 10
 
No Total
 
Disability Disability am able to engage in all my recreation activities, with no pain at all.
 
I can’t do any recreation activities at all.
 
In the past few weeks how much distress have you had with the following symptoms? Please mark the number which best indicates the level of distress you have experienced.
 
 
 
18. Have you been jumpy or startled easily?
 
Y N 
 
How would you rate this on a scale.
 
Not at All Minimally Moderately Markedly Extremely
 
0 1 2 3 4
 
 
 
19. Have you been physically upset by reminders of the event?
 
Y N 
 
How would you rate this on a scale.
 
 
Not at All Minimally Moderately Markedly Extremely
 
0 1 2 3 4
 
 
 
20. Have you been irritable, or had outburst of anger?
 
Y N 
 
How would you rate this on a scale.
 
Not at All Minimally Moderately Markedly Extremely
 
0 1 2 3 4
 
 
 
21. Have you been unable to have sad or loving feelings, or have you generally felt numb?
 
Y N 
 
How would you rate this on a scale.
 
Not at All Minimally Moderately Markedly Extremely
 
0 1 2 3 4
 
 
 
22. What are your chances of recovery?
 
How would you rate this on a scale where 0 is none & 10 the most.
 
0 1 2 3 4 5 6 7 8 9 10
 
I will recover    ​       No chance that I will recover
 
Thank you
 
That completes the questions for this triage assessment.
 
 
 
 
 
Triage display
 
 
 
 10. Do you have problems with Personal care?
 
This would include getting dressed or taking a shower etc.
 
0 ​ 1 ​ 2 ​ 3 ​ 4 ​ 5 ​ 6 ​ 7 ​ 8 ​ 9 ​ 10
 
No problem. I do not get dressed;
 
I wash with difficulty
 
I stay in bed.
 
 
 
Back forward button
 
Save function.
 
Prompt function not filled in one section
 
Help button
 
The questions either require a simple yes or no or they may require a score out of 10.
 
 
 
Here is an example of the type of questions you will be asked
 
 
 
A. I like apples.
 
 
 
0 ​1 ​2 ​3 ​4 ​5 ​6 ​7 ​8 ​9 ​10
 
Not at all ​          Very much
 
 
 
If you really like apples you would click on number 10, if you really hate apples you could click 0.
 
Please make an attempt at all the questions even if you don't think they really apply to you
 
Triage Scoring to be displayed
 
Date of Accident
 
Type of Accident
 
Severity of Injury
 
Severity of Injury
 
Pain 4days
 
Pain Now
 
No. of body parts
 
Areas of body – list e.g. Arm
 
No Health Professionals
 
Composite score 5 7 8 9 10/50=P score%
 
Existing Problem in those areas Y N
 
Disability Index – Effect on;
 
Personal care
 
Domestic Duties
 
Work
 
Travel
 
Sleep
 
Mood
 
Recreation
 
Flash backs
 
Chances of recovery
 
Composite Score Qu 11+12+13+14+15+16+17+22/80=D score%
 
Need help with recovery
 
SPAN Score
 
Total of Questions 18-21. >5 PTSD likley
 
Action
 
A&B Email
 
Results
 
For P3 if;
 
 
 
4. If indicate Want therapy
 
score >=4 in any category display delayed recovery
 
 
 
1. The Injuries sustained by the claimant. (question 5 answer)
 
MSK Y N
 
PTSD Y N
 
Psychological Y N
 
Other Y N txt
 
 
 
2. The current disability/incapacity arising from those Injuries.
 
Where relevant to the overall picture of the claimant’s needs, any other medical conditions not arising from the accident should also be separately annotated.
 
Work Y N
 
Domestic Y N
 
Travel Y N
 
 
 
3. The claimant’s domestic circumstances (including mobility accommodation and employment) where relevant.
 
Travel Y N
 
Self care Y N
 
Dependants Y N
 
 
 
4. The injuries/disability in respect of which early intervention or early rehabilitation is suggested.
 
WAD Y N
 
MSK Y N
 
Other Y N txt
 
 
 
5. The type of intervention or treatment envisaged.
 
Physio Y N
 
Pyscholgical Y N
 
Taken from question 1 answers
 
 
 
6. The likely cost.
 
Standard Physio Price
 
Standard Psychological
 
Assessment
 
P3
 
 
 
7. The likely outcome of such intervention or treatment.
 
RTW
 
Pain reduction Y N
 
Domestic Duties Y N
 
Travel Y N
 
Self care Y N
 
Sample responses;
 
 
 
1. The Injuries sustained by the claimant.
 
MSK Y
 
PTSD N low likleyhood
 
Psychological N low likleyhood
 
Other N
 
The client sustained musculoskeletal injuries
 
The client sustained musculoskeletal and possiblre injuries
 
 
 
2. The current disability/incapacity arising from those Injuries.
 
Where relevant to the overall picture of the claimant’s needs, any other medical conditions not arising from the accident should also be separately annotated.
 
Work Y
 
Domestic Y
 
Travel N
 
 
 
3. The claimant’s domestic circumstances (including mobility accommodation and employment) where relevant.
 
Travel N
 
Self care Y
 
Dependants Y
 
 
 
4. The injuries/disability in respect of which early intervention or early rehabilitation is suggested.
 
WAD Y
 
MSK Y
 
Other N
 
 
 
5. The type of intervention or treatment envisaged.
 
Physio Y
 
Pyscholgical N
 
 
 
6. The likely cost.
 
Standard Physio Price AssessmentP3
 
 
 
7. The likely outcome of such intervention or treatment.
 
RTW
 
Pain reduction Y
 
Domestic Duties Y
 
Self care Y
 
Notes for telephone triage:
 
This is a question her to censure triaged medicolegal patients.
 
It is intended as a brief summary of their condition and not a detailed medical report.
 
If when filling in the questions that can’t manage to answer one/ them please make them have their best guess.
 
Reassure them this is not to be held against them in any future cases just so we can assess their medical needs now.
 
Notes on questions.
 
 
 
6. Did you have an existing problem in the area refers to your neck pain now from accident
 
Paint before what have they ever injured area before cynical back pain and leg pain or so on.
 
 
 
16. Mood relates to depression you feel down either because of the pain or for other reasons.
 
At the end of questionnaire thank them and tell them that the complexity of angel Bowden.
 
If they press you for any medical information please say that this doesn't constitute a medical consultation millions triaged and that you be in contact soon. There is any further pressing questions they can e-mail us or contact their GP because of medical nature.
 
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