Fillable Medical report form (RTA3) (London School of Business & Finance)

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Medical report form (RTA3) (London School of Business & Finance)

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The Medical report form (RTA3) (London School of Business & Finance) form is 7 pages long and contains:

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1
Medical report form (RTA3)
Low value personal injury claims in road trac accidents (£1,000 to £25,000)
Section A — Claimant’s details
Claimant’s full name
Address
Date of birth
/ /
Occupation
Postcode
1.1
Were medical records provided? Yes No
If Yes, which records were seen?
1.2
Has photo ID been conrmed? Yes No
If Yes, what type of photo ID was checked
If No, what other ID was provided
1.3
Age of the claimant at time of accident?
1.4
Date of examination
/ /
1.5
Date of report
/ /
1.6
Name of instructing solicitors/agency
1.7
MedCo Case ID (Soft tissue injury claims only)
RTA3 Medical report form (04.15)
2
Section B
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 occured.
Present position reported by claimant
Please detail all ongoing symptoms reported at examination
3
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 diculties, symptoms and/or restrictions.
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.
4
Section D
Past medical history
Please refer to any relevant history based on examination or records as appropriate.
Medicial records should be considered where appropriate. Where records have been
considered please conrm which records are relevant to the claim.
On examination
Please state your ndings on examination including the details of any restrictions arising
from the accident.
5
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
identied 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 nal prognosis;
- if a report is needed from a medical expert of a dierent discipline; or
- if a follow up report is needed.
Section D - continued
6
Section E
Section F
Future treatment and rehabilitation
Please give details of any further treatment and/or rehabiliation that the
claimant will require.
Seatbelts
Was the claimant wearing a seatbelt? Yes No
Does the claimant have an exemption from wearing a seatbelt?
Yes No
If Yes, please state form of exemption
If No, please state to what extent would each of the claimant’s injuries have been prevented
all together; have been less severe; or have been unchanged by the claimant’s failure to
wear a seatbelt?
7
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 conrm 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 conrm to be
true. The opinions I have expressed represent my true and complete professional opinions on the
matters to which they refer.
Signature
Date
/ /
8
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Medical report form (RTA3) (London School of Business & Finance)

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Completed 3 December 2020

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