Patient Questionnaire
Thank you for attending a medico-legal assessment in relation to your accident/injury.
The examination is an independent and honest effort to assess your condition. Due to the nature
of the assessment requested, the doctor cannot offer you any treatment advice or provide you
with an opinion.
Privacy Disclosure
The doctor you are seeing is an expert in diagnosing and advising about conditions such as yours.
He (or she) will write a report based on what he (or she) learns from you as well as the
information that has been forwarded by the referring party. The information will assist the
doctor in preparing a quality and comprehensive report concerning your current medical status.
Your assistance in providing this information is greatly appreciated.
Some of the questions are of a personal nature but are necessary for the preparation of a
comprehensive report. The doctor will ask you about your work history; about your accident or
circumstances that caused your injury or condition. He will ask you about the treatment you have
had and about how the injury or condition has affected you. He will also ask you about your past
medical history.
Thank you for providing your personal information including the information about your health.
The report will be sent to the person who has arranged the examination.
Our Privacy Policy is available on request for you to read if you wish. If you have any queries,
please do not hesitate to discuss the matter with us or the doctor you are seeing for this
assessment.
Please sign the other page of this form to proceed with the independent medical
examination.
Thank you for your cooperation.
Appointment with a Psychiatrist
FULL NAME:
CURRENT ADDRESS:
POST CODE:
DATE OF BIRTH:
MARITAL STATUS: (married/single etc)
MOBILE NUMBER or TELEPHONE NUMBER:
EMPLOYER AT TIME OF INJURY: (if applicable)
OCCUPATION AT TIME OF INJURY:
I CONSENT TO THIS MEDICAL EXAMINATION
I AUTHORISE THE DOCTOR TO PREPARE AND FORWARD A MEDICAL REPORT ON MY CONDITION
TO THE REFERRING SOURCE OR ITS AGENT
I UNDERSTAND THAT THE MEDICAL EXAMINATION FOR WHICH I AM PARTICIPATING IN THIS
TELEHEALTH APPOINTMENT IS NOT FOR THE PURPOSE OF TREATMENT OF MY CONDITION
AND NO MEDICAL ADVICE WILL BE GIVEN TO ME BY THIS EXAMINING DOCTOR.
SIGNATURE: DATE:
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