Medical Report Trauma to the Neck or Base of the Skull Cerebrovascular Accident



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Medical Report - Trauma to the Neck or Base of the Skull

Cerebrovascular Accident

The information you provide on this form will assist in deciding eligibility for benefits under the Veterans' Entitlements Act 1986 and/or Military Rehabilitation and Compensation Act 2004. In the event of an appeal against a decision, this information may be provided to the Veterans' Review Board, Administrative Appeals Tribunal or Federal Court.



Veteran's Details

Surname




Given Names




DVA File Number
















Report Detail

A claim for service related compensation in respect of the above named leads the Department to consider whether trauma to the neck or base of the skull* could be relevant to the development of (insert claimed position) in this case. *Note: The Repatriation Medical Authority (RMA) defines this type of trauma to mean either:



  1. a non-penetrating injury, involving extension, rotation, hyperflexion or compression of the neck;

  2. a penetrating injury to the neck or the base of the skull; or

  3. an injury resulting in fracture or dislocation of the cervical spine.

Would you please answer the following questions.

1. When was the clinical onset of (________________________________)?………./………./……….

2. Has the veteran suffered from a trauma to the neck or the base of the skull, as defined by the RMA?

No - Please sign the form and return it to the Department



Yes - When did this trauma to the neck or the base of the skull occur?

/ /

3. Please describe the nature and extent of the injury sustained?










4. How did the trauma to the neck or the base of the skull occur? Did the trauma occur as a consequence of a medical or surgical condition? (eg a fall occurring as a result of epilepsy.) If so, what was the condition?













Details of Medical Practitioner providing advice:

Stamp






















Signature

























/ /




CSMG010MR9104 19/06/1996


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