Premier Healthcare of Placerville
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- Samuel Derick Warren
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1 Premier Healthcare of Placerville 1980 Broadway, Placerville, CA (530) Fax (530) WORKERS COMPENSATION INJURY QUESTIONNAIRE Name: Social Security#: of Birth: Today s : To insure greater accuracy in the assessment of your condition, we ask that you answer the following questions as completely as possible. Please sign the bottom of each page in the space provided. 1. What is your chief complaint (s)? 2. Have you ever seen any of our doctors before? ( ) Yes ( ) No If so, When? 3. What was the date and time of your accident? : Time: 4. Who was your employer at the time of the accident? 5. How long had you worked with the above employer prior to this injury? 6. Name all employers you have worked for the past five years What type of work were you doing when this injury occurred? 8. Where did the accident happen? 9. How did the accident happen? 10. Was the accident reported to someone? ( ) Yes ( ) No If so, Who? 11. Have you had any other serious accidents which required medical care? ( ) Yes ( ) No If so, When? 12. Have you ever been awarded any type of disability? ( ) Yes ( ) No If so, For What? By Who? Page 1 of 5
2 13. What medical care have you received as a result of this injury, from whom and for how long? 14. I am ( ) improved ( ) unchanged ( ) getting worse. 15. What medicines are you talking, if any? 16. Does the medicine help? If yes How? If no Why? 17. Have you had Physical Therapy? ( ) Yes ( ) No If yes, How often? 18. Did the Physical Therapy help? ( ) Yes ( ) No 19. Have you ever had any physical complain similar to those that you are now complaining of before this accident? Please discrbe: 20. Have you had any serious illnesses that required hospitalization? ( ) Yes ( ) No If yes, Describe 21. Have you had any surgeries, and when? ( ) Yes ( ) No If yes, Describe 22. Hve you had any fractures, and when? ( ) Yes ( ) No If yes, Describe 23. Have you had any nervous our mental illnesses? Any phychiatric care? If yes, Describe 24. Have you received a medical discharge from the Armed Forces? ( ) Yes ( ) No 25. Have you returned to work since this accident? ( ) Yes ( ) No If you have retured to work since your work accident, please fill out the chart below including dates you have worked,for whom and occupation. DATE EMPLOYER OCCUPATION LIGHT/REG.DUTY FULL/PART TIME Page 2 of 5
3 BACK PAIN I have pain in my: ( ) low back ( ) mid back ( ) upper back My pain began: ( ) gradually ( ) suddenly I have pain: ( ) sometimes ( ) all of the time My pain goes into my: ( ) right leg ( ) left leg ( ) both I have tingling and/or numbness in my: ( ) right leg ( ) left leg ( ) both My pain is works when I: cough or sneeze ( ) Yes ( ) No sit ( ) Yes ( ) No bend ( ) Yes ( ) No walk ( ) Yes ( ) No lift ( ) Yes ( ) No push ( ) Yes ( ) No pull ( ) Yes ( ) No My back is worse with sexual activity: ( ) Yes ( ) No My pain wakes me up in the middle of the night ( ) Yes ( ) No Changes in the weather affect my pain: ( ) Yes ( ) No NECK PAIN My pain began: ( ) gradually ( ) suddenly I have pain: ( ) sometimes ( ) all of the time My pain goes into my: ( ) right arm ( ) left arm ( ) both I have tingling and/or numbness in my: ( ) right arm ( ) left arm ( ) both My pain is works when I: cough or sneeze ( ) Yes ( ) No bend forward ( ) Yes ( ) No lift ( ) Yes ( ) No push ( ) Yes ( ) No pull ( ) Yes ( ) No turn my head ( ) Yes ( ) No I have tingling and/or numbness in my: ( ) right arm ( ) left arm ( ) both My pain wakes me up in the middle of the night ( ) Yes ( ) No Page 3 of 5
4 Changes in the weather affect my pain: ( ) Yes ( ) No Neck Pain Continued: I have neck stiffness: ( ) Yes ( ) No I have headaches: ( ) Yes ( ) No If I do get headaches, they occure: ( ) Sometimes ( ) All of the time Please use the space provided below to descibe any current medical complaints you are experiencing which were not previously covered on the questionnaire or for any additional comments you wish to make regarding your condition. Page 4 of 5
5 Employee Description of Job Requirements Employee Name: 1 Check the frequency of activity required of the employee to perform the job: ACTIVITY (Hours per day) (0 hours) Occasionally (up to 3 hours) (3-6 hours) (6-8 hours) a. Sitting b. Walking c. Standing d. Bending (neck) e. Bending (waist) f. Squatting g. Climbing h. Kneeling i. Crawling j. Twisting (neck) k. Twisting (waste) Hand Use: Dominant hand R L 1. Repetitive use of had required 2. Simple grasping (right hand) 3. Simple grasping (left hand) 4. Power grasping (right hand) 5. Power grasping (left hand) 6. Fine maniupulation (right hand) 7. Fine maniupulation (left hand) 8. Pushing and pulling (right hand) 9. Pushing and pulling (left hand) 10. Reaching (above shoulder level) 11. Reaching (below shoulder level) 12.Typing/Computer 2. Please indicate the daily lifting and carrying requirements of the job: Indicate the height the object is lifted from floor, table or overhead location and the distance the obect is carried. LIFTING CARRYING 0 hours Occassionaly 0 3 hours 3-6 hours hours Height 0 hours Occassionaly 0 3 hours 3-6 hours hours Distance 0-10 lbs lbs lbs lbs lbs lbs. Describe the heaviest item required to cary and the distance to be carried. Page 5 of 5
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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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341 Magnolia Avenue, Suite 101 28078 Baxter Road, Suite 330 Corona, CA 92879 Murrieta, CA 92563 (951) 735-6060 (951) 735-4510 Fax (951) 677-2157 www.ctoamg.com WORKER S COMPENSATION HISTORY FORM NAME (Last,
LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B
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Accountant I, II, III, Supervisor Risk Management 1010 10 th Street Modesto, California 95354 (209) 525-5770 Date: February 2007; January 2016
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