11/11/1911. Occupation. Accountant. None 01/01/ Years 15/02/ /02/2011 PICAS-W

Transcription

1 Medical report form The first report is without notes except where requested by medical experts Section A Claimant's details Claimant's full name Mr Yvonne05 Test Date of birth 11/11/1911 Occupation Address 47 Broadmarsh Business & Innovation Centre Harts Farm Way Havant PO9 1HS Accountant Accompanied by Attended alone 1.1 Has photo ID been confirmed? Yes X No Records reviewed Yes X No If Yes, what type of photo ID was checked? If No, what other ID was provided? None 1.2 Date of accident 01/01/ Age of the claimant at time of accident Date of examination Place of examination 99 Years 15/02/ Broadmarsh Business & Innovation Centre, Harts Farm Way, Havant PO9 1HS, United Kingdom Date of report Name of instructing solicitors/agency PICAS-W /02/2011 Instructor: PREMIER - MH Instructor Ref: Unknown Agency: Premier Medical Agency Ref: Premier Medical Group, Premier House, Eco Business Park, Ludlow, Shropshire, SY8 1ES Telephone: Fax: Page 1 of 9

2 Section B Statement of Instruction This medical report is produced for Court purposes. It is an impartial report, my initial written instructions in this case were received from PREMIER - MH. Reference - Unknown. It refers to injuries sustained by Mr Test on 01/01/2011. History Please give a brief description of the accident, immediate symptoms and treatment. Include a history of treatment, specifying whether the claimant was treated as an in-patient or outpatient where applicable. Detail any improvement or deterioration of symptoms including dates. In the case of injuries/symptoms fully recovered, please specify the date by which there was a full recovery, whether the claimant has ever experienced symptoms in the injured area prior to the accident and if so, give full details including type of injury and date it occurred. The Accident 1. Immediate Symptoms Mr Test reports that he: Did not notice any symptoms at the time of the accident. Later Symptoms Mr Test reports that he: Did not develop any other symptoms following the accident. Immediate Treatment Mr Test did not receive any treatment at the scene of the accident. He then went to an appointment by ambulance. Later Treatment Mr Test has not used medication, attended physiotherapy, nor been referred to a specialist as a result of the accident. Investigations Mr Test did not have any investigations. Page 2 of 9

3 Present position reported by the claimant Please detail all ongoing symptoms reported at the examination. None Page 3 of 9

4 Section C Employment position/education Please give details of the claimant s employment/education at the time of the accident. Include the dates of any absences, part-time work or light duties undertaken and the nature of any light duties. Set out the claimant s current situation at work/educational establishment including any practical difficulties, symptoms and/or restrictions. His main occupation is as an Accountant for 1 hours per week. Mr Test has not taken any time off because of the accident. Despite the accident, he has been able to fulfil his normal duties. Consequential effects Please state the impact on other activities such as hobbies, recreations, housework, gardening, travelling, holidays, shopping, sex life. Give details as to the claimant's general state of mind. Home Circumstances: Mr Test lives alone. Travel: Mr Test reports that he has had no problems with travel. Daily Living: Mr Test reports that since the accident: He did not suffer any restriction of his personal care or his home life. Page 4 of 9

5 Section D Past medical history Please refer to any relevant history based on examination or records as appropriate. Post accident records should be considered where appropriate. There was no relevant past medical history. On examination Please state your findings on examination including the details of any restrictions arising from the accident. Dominant Hand: Mr Test is right-handed. General Appearance: Mr Test looked well. He appeared to move easily during the assessment. Mental Health: Based on the interview and my clinical observations, today: Mr Test was not suffering from anxiety. He was not depressed. Injuries, Wounds, Scars and Other Examination Findings: No wounds or scars were seen. Examination of the Neck: Examination of the neck was normal. Examination of the Upper Limbs: Examination of the upper limbs was normal. Examination of the Back: Examination of the back was normal. Examination of the Lower Limbs: Examination of the lower limbs was normal. Page 5 of 9

6 Diagnosis opinion and prognosis Please state your overall opinion of the claimant s position to date dealing with causation and including a prognosis if possible. Set out all reported symptoms and restrictions identified under the claimant s present position. Refer to the claimant s employment/education position and any impact to the claimant's home life. Please detail whether you consider that the claimant has/will make a recovery and to what extent and when this will be reached. Identify if the claimant has any further needs, including but not limited to: - if further treatment is necessary; - if time is needed to make a final prognosis; - if a report is needed from a medical expert of a different discipline; or - if a follow up report is needed. Opinion I was able to obtain a good history. His injuries were entirely consistent with the account of the accident. The claimant's treatment has been appropriate. Job Prospects Mr Test is currently fully fit for work. In the long term, his employment prospects are likely to be unaffected. Prognosis Mr Test currently has no symptoms related to the accident. Page 6 of 9

7 Section E Seatbelts This accident is not a standard RTA, therefore this section is not applicable. Page 7 of 9

8 Section F Future treatment and rehabilitation Please give details of any further treatment and/or rehabilitation that the claimant will require. None Page 8 of 9

9 Section G Statement of truth Civil Procedure Rule 35.3 states that it is the duty of experts to help the court on matters within their expertise. This duty overrides any obligation from whom experts have received instructions or by whom they are paid. I confirm that I have made clear which facts and matters referred to in this report are within my own knowledge and which are not. Those that are within my own knowledge I confirm to be true. The opinions I have expressed represent my true and complete professional opinions on the matters to which they refer. Signature Dr Hybrid Test MB ChB Date 15/02/2011 Page 9 of 9