A helpful way to gather information from a person subject to an IME (an examinee) is through the use of a written questionnaire. Please see the below sample IME questionnaire.  Note that the below form can also serve as a helpful reference for IME physicians when taking the history from an IME examinee.  The examinee’s signature at the end of this form can also potentially protect the IME physician against claims that the examining physician hurt the examinee during the examination. 

Independent Medical Evaluation Questionnaire

We will be seeing you soon for your independent medical evaluation. We pledge that we will be both thorough and impartial.  During this visit no treating physician/patient relationship will be established.  The purpose of this visit is to answer specific questions concerning your case and to prepare a report.  The information that you share with us will be included in the report.  If anyone else needs a copy of this report, it is best to obtain it directly from the organization requesting this evaluation.

During the visit we will review your history, medical records, and any available studies. We will also perform a physical examination.  If you have any difficulties whatsoever during the assessment you should let us know immediately.  To adequately understand your case, we need to carefully review your history.  Please complete this questionnaire and bring it with you to the examination.  We will review all of this information at the time of your visit.  We look forward to seeing you.

  1. What is your full name?
  2.  What is your date of birth?
  3.  Are you?         __ Right Handed     __ Left Handed     __ Either
  4.  What is the date of your injury?
  5.  Have you ever had any previous problems or injuries, including any other work-related, recreational, or motor vehicle injuries?
    __ Yes __ No   __ Not sure
    If yes, please describe:
  6. Have you ever had any difficulties prior to the date of your injury that were similar to those you are now experiencing?      __ Yes __ No   __ Not sure
    If yes, please describe:
  7.  Please describe how your injury occurred:
  8.  What problems did you have at that time?
  9. What did you do following the injury?
  10.  Briefly describe what has occurred since that time to this date:
  11.  What is your greatest concern at this time? If you are not having difficulty with pain, proceed to question 18.
  12.  Where is your pain located?
  13.  How would you describe your pain?
  14.  What makes your pain worse?
  15. What makes your pain better?
  16. How frequent is your pain?
    __ constant  (present 3/4 to all of the time)
    __ frequent  (present 1/2 to 3/4 of the time)
    __ occasional (present 1/4  to 1/2  of the time)
    __ intermittent  (present less than 1/2 of the time)
  17. On a scale from 0 (no pain) to 10 (excruciating pain):
    a.  What number would you put on your pain at this time?                     ______
    b.  During the past month, what has it averaged?                                      ______
    c.  During the past month, what is the highest it has been?                     ______
    d.  During the past month, what is the lowest it has been?                      ______
  18.  Are you having any other difficulties?                                              __ Yes __ No  __ Not sure
    If yes, please describe these difficulties in detail:
  19.  Are any tasks difficult for you to perform?                                        __ Yes __ No   __ Not sure
    If yes, please describe the tasks that are most difficult for you: If your injury is not work-related, please proceed to question 28.
  20.  Who were you employed by when you were injured?
  21.  How long had you been working there?
  22.  What was your job?
  23.  What did this job involve?
  24.  What type of work have you performed previously?
  25.  What is your level of education?
  26.  Are you working now?     __ Yes __ No
    Please describe:
  27.  Has your doctor, or anyone, prescribed any work restrictions?                     __ Yes __ No __ Not sure
    If yes, please describe these restrictions:
  28.  Where do you live?
  29.  Who lives with you?
  30.  Please describe your typical day:
  31.  Are you involved in any work activities or any significant recreational pursuits?      __Yes __ No  __Not sure
    If yes, please describe:
  32. Do you smoke?    __No   __ Yes, in the past, but I quit           __  Yes, ______ packs per day
  33.  How many alcoholic beverages do you have per week?    _______________
  34.  Have you had any medical hospitalizations?       __ Yes __ No __ Not sure
    If yes, please describe:
  35. Have you had any operations?        __ Yes __ No __ Not sure
    If yes, please describe:
  36. Are you taking any prescribed medications?     __ Yes __ No __ Not sure
    If yes, please list:
  37. Are you allergic to any medications?         __ Yes __ No __ Not sure
    If yes, please describe:
  38. Have you had any other medical problems?     __ Yes __ No __ Not sure
    If yes, please describe:
  39. Do any diseases run in your family?         __ Yes __ No __ Not sure
    If yes, please describe:
  40. Please provide any other comments that may assist us in understanding your situation: Thanks for your assistance. At the time of the visit we will review this information in further detail.

I understand that I am being seen for an independent medical evaluation and no treating physician/patient relationship is established. I understand that the information I discuss will be included in a report that is prepared for the requesting client.  I consent to this report being sent to this client and to participating in the assessment.  I agree to advise the physician immediately if I experience any difficulties during the examination.

Signed:             _________________________________________________ 

Date:                ________________________________________________

 

Witness:           _______________________________________________