\ MedicoLegal Introductory Form MedicoLegal Introductory Form First Name*Last Name*Most Recent Occupation*Company*Phone*Email*Age*1617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162636465666768697071727374757677787980818283848586878889909192939495Handedness*LeftRightAmbidextrousDid your symptoms occur following an injury?*YesNoWhen approximately did your symptoms begin?*If exact day and/or month is unknown, please enter just the month and/or year.My injury was...*a work-related injurya motor-vehicle related injurynot work or motor vehicle relatedWhat was the date of your work injury or motor vehicle accident?*If exact day and/or month is unknown, please enter just the month and/or year.Employer at the time of injury*Beginning date with this employer*Please list a few of the most physically demanding aspects of your work with this employer*Have you had a past injury or symptoms in the same area as your current injury or pain?*YesNoHave you seen a doctor previously for back or neck pain?*YesNoHave you had other treatment for neck or back pain before your current injury or symptoms?*YesNoIf you previously had an injury, pain or other symptoms in the same area as your current problem, did you make a full recovery?*Yes: No on-going pain or treatments requiredNo: Mild on-going symptoms not requiring treatmentNo: I had on-going symptoms requiring treatmentPlease complete the below questions pertaining to your educational history.What year of high-school have you completed? (i.e. year 9, 10, 11, 12)If you have completed a university degree, please specifyIf you have completed a postgraduate university degree, please specifyIf you have completed an apprenticeship, please specifyIf you have completed any certificates, please specifyPlease list any previous occupationsPlease select the relationship status that is most appropriate to youSingleDe-facto relationshipMarriedSeparatedDivorcedOtherDo you have any children?*YesNoPlease specify the number of children*Do you smoke cigarettes?*YesNoPlease specify the number of cigarettes per day*Do you drink alcohol?YesNoPlease specify the number of drinks per week*Work StatusAre you currently working?*YesNoPlease specify the details of your current job below:Job Title/Position*Hours Per Week*Duties at your current job areNormalModified/RestrictedIf you were working with modified duties, please list the restrictions*When approximately did you last perform any type of work?*If exact day and/or month is unknown, please enter just the month and/or year.Please specify the details of the job you last work below:Job Title/Position*Hours Per Week*If there were restrictions where you last worked, please specify*Why did you cease your previous work?*Made redundant or terminatedStopped work due to painOther (please specify)Reason for ceasing previous work*Are you currently studying?*YesNoHow many hours per week?*Symptoms & Previous TreatmentPlease list your main 5 symptoms, starting with the most severe and ending with the least severe (if less than 5, leave blank)Symptom 1Symptom 2Symptom 3Symptom 4Symptom 5Please select any of the following you have experienced:Urinary incontinencePoor urinary streamDifficulty starting urinationDifficulty completely emptying bladder during urinationFecal incontinenceNumbness around the anus and/or genitalsRecent difficulties with erectionsFeverUnexplained weight lossHistory of cancerProblems walking (apart from those due to leg pain)Significant back or neck pain at nightFoot dropLeg weaknessArm weaknessLoss of hand strengthElectric shocks down the spine on certain neck movementsPlease list any current medicationsInclude medication name, dosage, and frequency. One medication per line, please. Example: Aspirin, 4mg, 3 times a day Panadeine Forte, 500mg, 7 times a dayPlease list the frequency with which you meet with the following specialists Please answer in terms of weeks (i.e. once per week, every two weeks, three weeks etc) If you don't see the below specialist, simply enter N/APhysiotherapyHydrotherapyReview by PsychologistReview by PsychiatristReview by Specialist (Please specify type)OtherHave you previously had spinal surgery?YesNoOperation NameSurgeonMonth & Year(If known)Did you benefit from this procedure?YesNoFor the below treatment types, please select whether or not you have previously benefited from their utilization. If you have not used the treatment previously, please select No Previous Treatment.MedicationBenefitNo BenefitNo Previous TreatmentPhysiotherapyBenefitNo BenefitNo Previous TreatmentHydrotherapyBenefitNo BenefitNo Previous TreatmentChiropracticBenefitNo BenefitNo Previous TreatmentOsteopathyBenefitNo BenefitNo Previous TreatmentPsychologyBenefitNo BenefitNo Previous TreatmentPsychiatryBenefitNo BenefitNo Previous TreatmentPain Management ProgramBenefitNo BenefitNo Previous TreatmentPain Injections (Cortisone or Anaesthetic)BenefitNo BenefitNo Previous TreatmentRadiofrequency DenervationsBenefitNo BenefitNo Previous TreatmentSpinal Cord StimulationBenefitNo BenefitNo Previous TreatmentOther (Please specify)LifestylePlease rate the degree to which your social life is impacted by your symptomsNot at allSlightly impactedModerately impactedSeverely impactedPlease select if any of the below factors contribute to an impaired social life.N/ASitting intoleranceStanding intolerancePain severityInability to driveEffects of medicationConcern about re-injuryOtherSelect "N/A" if your social life is not impaired. Please rate the degree to which your ability to take part in recreational activities is impacted by your symptomsNot at allSlightly impactedModerately impactedSeverely impactedPlease list any specific recreational activities that are impacted by your injuryPlease rate the degree to which your sleep quality is impacted by your symptomsNot at allSlightly impactedModerately impactedSeverely impactedPlease rate the degree to which your overall quality of life is impacted by your symptomsNot at allSlightly impactedModerately impactedSeverely impactedPlease list other factors that contribute to an impaired social life.For the remainder of this survey, you will be prompted with a simple yes or no question as to whether you're experiencing pain in specific regions of your body. If you select yes, you will be asked additional questions relevant to that body area. If you select no, you will not complete questions related to that part of the body, and skip to the next body area. Importantly, many pain regions will not be relevant to you. You are not expected to complete every section Lower BackAre you presently experiencing lower back pain?YesNoMy lower back pain is...Constant - present all the timeIntermittent - comes & goesHow many times per day would you experience an episode of lower back pain?How long would a typical episode of lower back pain last?(Answer in hours, i.e. 0.5, 1, 2 etc)Please select the best describer of your lower back pain (select all that apply)SharpDullBurningThrobbingGnawingStabbingAchingWhich of the below best describes the location of your lower back pain?Left-sidedRight-sidedToward the middleBoth sidesBoth sides, but worse on the rightBoth sides, but worse on the leftMy lower back pain...Radiates into my hips/buttocks/groin/legsRemains in my lower back onlyAverage lower back pain severity Please rate the average severity of your lower back pain. 0 (no pain at all) 100 (worst pain imaginable) Maximum lower back pain severity Please rate the maximum severity of your lower back pain. 0 (no pain at all) 100 (worst pain imaginable) Please select any of the items below that exacerbate your lower back painSittingStandingBendingTwistingLiftingPushing or PullingCoughing or SneezingStrainingWalkingFor the below activities, how long can you do them for before experiencing lower back pain? (Answers in minutes)WalkSitStandPlease select any of the items below can help relieve your lower back painRecumbency (lying down)Frequent postural changesGentle excerciseHeat packsMedicationsOtherPlease list other remedies that relieve your lower back painLegsAre you presently experiencing leg pain?YesNoMy leg pain is...Constant - present all the timeIntermittent - comes & goesHow many times per day would you experience an episode of leg pain?How long would a typical episode of leg pain last?(Answer in hours, i.e. .5, 1, 2, etc)Please select the best describer of your leg pain (select all that apply)SharpDullBurningThrobbingGnawingStabbingAchingWhich leg do you experience pain in?Left legRight legBoth legsBoth legs, but the left leg is worseBoth legs, but the right leg is worsePlease select from below the areas of your leg(s) experiencing pain (select all that apply)Entire leg(s)ButtocksHamstringsHamstrings + kneeCalfCalf + shinFront of legFront of leg + kneeFront of leg + knee + shinSole of footTop of footBig toeIf entire leg is in pain, please select the first option "Entire leg(s)" Please rate the average severity of your leg pain. 0 (no pain at all) 100 (worst pain imaginable) Average leg pain severity Please rate the maximum severity of your leg pain. 0 (no pain at all) 100 (worst pain imaginable) Maximum leg pain severityPlease select any of the items below that exacerbate your leg painSittingStandingBendingTwistingLiftingPushing or PullingCoughing or SneezingStrainingWalkingHow much can you lift before experiencing leg pain(Answer in kg)For the below activities, how long can you do them for before experiencing leg pain? (Answers in minutes)WalkSitStandLeg Numbness and/or Pins & NeedlesAre you presently experiencing leg numbness and/or pins & needles?YesNoMy leg numbness and/or pins & needles are...Constant - present all the timeIntermittent - comes & goesHow many times per day would you experience an episode of numbness/pins & needles?How long would a typical episode of numbness/pins & needles last?(Answer in hours, i.e. 0.5, 1, 2 etc)Which leg do you experience leg numbness and/or pins & needles in?Left legRight legBoth legs equallyBoth legs, but the left leg moreBoth legs, but the right leg morePlease select from below, what parts of your leg experience numbness/pins & needles (select all that apply)Entire legs(s)Back of legFront of thighOutside of thighIn the shinHer the outside of the calfIn the back of the calfIn the entire footOutside the sole of footEntire soleTop of footIf entire leg has numbness or pins and needles, please select the first option "entire leg(s)"Mid-BackAre you presently experiencing pain in the mid-section of your back?YesNoMy mid-back pain is...Constant - present all the timeIntermittent - comes & goesHow many times per day would you experience an episode of mid-back pain?How long would a typical episode of mid-back pain last?(Answer in hours, i.e. 0.5, 1, 2 etc)Please select the best describer of your mid back pain (select all that apply)SharpDullBurningThrobbingGnawingStabbingAchingWhich of the below best describes the location of your mid back pain?Left-sidedRight-sidedToward the middleBoth sidesBoth sides but left is more painfulBoth sides but right is more painful Please rate the average severity of your mid-back pain. 0 (no pain at all) 100 (worst pain imaginable) Average mid-back pain severity Please rate the maximum severity of your mid-back pain. 0 (no pain at all) 100 (worst pain imaginable) Maximum mid-back pain severityPlease select any of the items below that exacerbate your mid-back painSittingStandingBendingTwistingLiftingPushing or PullingCoughing or SneezingStrainingWalkingFor the below activities, how long can you do them for before experiencing mid-back pain? (Answers in minutes)WalkSitStandPlease select any of the items below can help relieve your mid-back painRecumbency (lying down)Frequent postural changesGentle exerciseHeat packsMedicationsOtherPlease list other remedies that relieve your mid-back painHow much can you lift before experiencing mid-back pain(Answer in kg)NeckAre you presently experiencing pin in your neck and/or shoulders?YesNoMy neck pain is...Constant - present all the timeIntermittent - comes & goesHow many times per day would experience an episode of neck pain?How long would a typical episode of neck pain last?(Answer in hours, i.e. 0.5, 1, 2 etc)Please select the describer of your neck pain (select all that apply)SharpDullBurningThrobbingGnawingStabbingAchingWhich side of the neck do you experience pain inLeft side of neckRight side of neckAll over the neckBoth sides but left is more painfulBoth sides but right is more painfulPlease select from below which areas of the body of your neck pain radiates to (select all that apply)Neck onlyBack of the headLeft shoulderRight shoulderLeft armRight armBehind the left shoulder bladeBehind the right shoulder bladeIf pain is limited to neck only, please select the first option "Neck only" Please rate the average severity of your neck pain. 0 (no pain at all) 100 (worst pain imaginable) Average neck pain severity Please rate the maximum severity of your neck pain. 0 (no pain at all) 100 (worst pain imaginable) Maximum neck pain severityPlease select any of the items below that exacerbate your neck painSittingStandingRepetitive neck movementsSudden neck movementsKeeping neck in one position too longUsing computer for too longDriving for too longPushing or pullingCoughing or sneezingStrainingRepetitive arm movementsUsing arms above shoulder heightExtending neck (looking up)Flexing neck (looking down)Rotating neckPlease select any of the items below can help relieve your neck painRecumbency (lying down)Frequent postural changesGentle exerciseHeat packsMedicationsOtherPlease list other remedies that relieve your neck painFor the below activities, how long can you do them for before experiencing neck pain? (Answers in minutes)WalkSitStandUsing a computerHow much can you lift before experiencing neck pain?(Answer in kg)ArmsAre you presently experiencing pain in your arms?YesNoMy arm pain is...Constant - present all the timeIntermittent - comes & goesHow many times per day would you experience an episode of arm pain?How long would a typical episode of arm pain last?(Answer in hours, i.e. 0.5, 1, 2 etc)Please select the best describer of your arm pain (select all that apply)SharpDullBurningThrobbingGnawingStabbingAchingWhich of arm(s) do you experience pain in?Left armRight armBoth armsBoth arms but left is more painfulBoth arms but right is more painfulPlease select from below which areas of the body of your arm pain radiates to (select all that apply)Entire armTriceps (back of arm)Biceps (front of arm)ForearmWristFingersIf pain encompasses your entire arm(s), please select the first option "Entire arm"If pain extends to your fingers, please specify what fingers below (select all that apply)Entire handThumb mainlyThumb and index finger mainlyIndex finger mainlyIndex and middle finger mainlyMiddle and third finger mainlyThird and fourth fingers mainlyFourth and fifth fingers mainlyIf pain encompasses your entire hand(s), please select the first option "Entire hand" Please rate the average severity of your arm pain. 0 (no pain at all) 100 (worst pain imaginable) Average arm pain severity Please rate the maximum severity of your arm pain. 0 (no pain at all) 100 (worst pain imaginable) Maximum arm pain severityPlease select any of the items below that exacerbate your arm painSitting for too longStanding in one position for too longRepetitive neck movementsSudden neck movementsRepetitive neck movementsSudden neck movementsKeeping neck in one position too longUsing computer for too longDriving for too longPushing or pullingCoughing or sneezingStrainingRepetitive arm movementsUsing arms above shoulder heightExtending neck (looking up)Flexing neck (looking down)Rotating neckFor the below activities, how long can you do them for before experiencing arm pain? (Answers in minutes)WalkSitStandUsing a computerPlease select any of the items below can help relieve your arm painRecumbency (lying down)Frequent postural changesGentle exerciseHeat packsMedicationsOtherPlease list other remedies that relieve your arm painArm Numbness and/or Pins & NeedlesAre you presently experiencing arm numbness and/or pins & needles?YesNoMy arm numbness and/or pins is...Constant - present all the timeIntermittent - comes & goesHow many times per day would you experience an episode of arm numbness/pins & needles?How long would a typical episode of arm numbness/pins & needles last?(Answer in hours, i.e. 0.5, 1, 2 etc)Which arm do you experience numbness and/or pins & needles in?Left armRight armBoth armsBoth arms but left more numbBoth arms but right more numbPlease select from below what parts of your arm experience numbness/pins & needles (select all that apply)Entire arm(s)Triceps (back of arm)Biceps (front of arm)ForearmsElbowsWristsFingersIf entire arm has numbness or pins & needles, please select the first option "Entire arm(s)"If pins & needles/numbness extends to your fingers, please specify what fingers below (select all that apply)Entire handThumb mainlyThumb and index finger mainlyIndex finger mainlyIndex and middle fingers mainlyMiddle and third fingers mainlyThird and fourth fingers mainlyFourth and fifth fingers mainlyIf pins & needles/numbness encompasses your entire hand(s), please select the first option "Entire hand"HeadacheAre you presently experiencing headaches?YesNoHow many times per week would you experience a headache episode?How long would a typical headache episode last?(Answer in hours, i.e. 0.5, 1, 2 etc)Would you say your headaches typically occur when neck pain flares up?YesNoMy headaches are typically...Left sidedRight sidedBilateral (Both sides)Vary from left to right sidePlease select from below which parts of your head experience pain during a typical headache (select all that apply)Entire headBack of the headTop of headForeheadTemple region of headBehind the eyes (left, right, or both sides)If entire head has pain, please select the first option "Entire head"Please select any of the symptoms you experience below (select all that apply)Light sensitivitySound sensitivityNauseaVomitingBlurred visionSendThis field should be left blank
