Workers Compensation Patient Questionnaire
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- Thomasina Lloyd
- 7 years ago
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1 Workers Compensation Patient Questionnaire Name: Date: Age: Sex: Right / Left Handed (circle one) Please fill out this entire questionnaire so that we may have the most accurate information concerning you injury CURRENT COMPLAINTS What medical problem(s) is the doctor to see you for today? Please briefly describe your current complaints below. INITIAL HISTORY OF INJURY 1. When did you first notice this medical problem? Date: (Whether you paid attention to this condition or not.) 2. What do you feel caused this condition? 3. Who was your employer at the time you noticed this condition? 4. How did the injury / accident / condition happen? Please be specific. 5. What were the immediate symptoms? 6. Did you finish what you were doing?
2 7. Did you report the injury or problem? If yes, when: To whom: 2 HISTORY OF TREATMENT 1. When did you first see a doctor for this problem? 2. To which hospital or clinic were you taken? 3. Were you sent by your employer? If yes, please indicate which tests were done below. 4. Name of the doctor you saw? What type of doctor? 5. Were tests done? X-rays EMG Nerve Tests MRI Other: 2. What did the tests show? 3. What recommendations were made or what treatment was prescribed? a. Off work (dates): b. Hospitalized (give dates): c. Physical therapy (give dates, how often): d. Medication (give names): e. Casting: Splinting: f. Surgery (what kind, dates): List all other doctors that you have seen for this injury: Doctor s name: Type of doctor: Date last seen: were tests done? What did the test(s) show? What treatment was given? Hospitalized (dates): Physical therapy (duration & frequency): Medication (names): Casting: Splinting: Surgery [type(s) & date(s)]:
3 Which treatment helped? 3 Doctor s name: Type of doctor: Date last seen: were tests done? What did the test(s) show? What treatment was given? Hospitalized (dates): Physical therapy (duration & frequency): Medication (names): Casting: Splinting: Surgery [type(s) & date(s)]: Which treatment helped? Doctor s name: Type of doctor: Date last seen: were tests done? What did the test(s) show? What treatment was given? Hospitalized (dates): Physical therapy (duration & frequency): Medication (names): Casting: Splinting: Surgery [type(s) & date(s)]: Which treatment helped? Name of the doctor that you are currently seeing for this problem: Has your doctor released you to return to work? If YES, when were you released? Were you released to full duty or light duty? If LIGHT duty, what were your restrictions? Full / Light When did you actually return to work? If NO, state reason: Are you still working?
4 Are you working at your same job? Are you working a different job? 4 How is the work different from your previous job? WORK RECORD SINCE INJURY Have you missed any work because of the injury? List all dates that you have not been working. From to From to From to From to JOB DESCRIPTION Job title at the time of your injury: Employer at the time of your injury: Hours worked per day Days worked per week Overtime hours per week Work duties (describe what you do during an average work day): Maximum amount of weight that you would lift by yourself: How many times per day would you have to lift this amount? List any machines or tools that you routinely used at work: Check any activities required in the course of your work: Lift Carry Bend Stoop Squat Push Pull Climbing Walk Sit Stand Operate Equip. Operate Equip. Exposure Tools Hand Tools Power Repetitive Use Reach Forward Reach Overhead Awkward Positions
5 Number of years that you have worked for this employer: 5 Number of years that you have been in this line of work: PAST MEDICAL HISTORY Have you had previous injuries to any parts of your body involved in this claim? If yes, explain: Have you ever had any other work related injuries? If yes, list dates and injuries: Have you ever been hospitalized? If yes, list dates and reasons: Have you ever had surgery? If yes, list date(s) and procedure(s): List any motor vehicle accidents for which you received treatment: List current medications: List any allergies to medications: (Including adhesives, injectables or shellfish?) Check any of the following conditions which you have now or had in the past: Diabetes Thyroid Problems Rheumatoid Arthritis Heart Attack Stomach Ulcers Tuberculosis Cancer Kidney Problems High Blood Pressure Stroke Liver Disease Please List any other medical conditions:
6 SOCIAL HISTORY 6 Check one of the following: Married Single Divorced Separated Widow Do you have any children? If yes, how many? Your date of birth: Where you born? Highest education completed: Have you attended trade school? Hobbies: If yes, what kind? Recreational Activities: How much do you smoke? How much do you drink? For how long? For how long? Have you ever done any street drugs? If yes, what kind and how long ago? Have you ever been in an alcohol or drug rehabilitation program? MILITARY HISTORY None Navy Army Marine Corps Air Force Coast Guard National Guard Years of service: Date of discharge: PATIENT SIGNATURE: DATE OF FORM COMPLETION:
PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date:
WORKERS COMPENSATION HISTORY PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date: Address: City: State: Zip:
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First Name. Profession. Weight lbs. Weight 1 year ago lbs. Min. Adult Weight lbs. at age Maximum Weight lbs. at age
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Welcomes You Full Name: Today s Date: DOB: M / F Social Security #: DL# Address: City: State: Zip Code: Home # : Cell #: Occupation: Employer: Employer Address: Employer Phone: Employer Fax: Emergency
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Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:
TOTAL PAIN RELIEF. Also bring your medication so that we can review them with you and help answer any question you may have.
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