QUESTIONNAIRE. General Information. If yes, Medical No.: Employer Information (Time of Injury/Illness)

Transcription

1 QUESTIONNAIRE General Information Today s date: Referred by: Name: Home Telephone: Mobile Telephone: Date of Birth: Do you have Medi-Cal? Work Telephone: Social Security No.: If yes, Medical No.: Employer Information (Time of Injury/Illness) Employer: Telephone: Job Title: Hours Per Week: Date of Hire: Pay Rate: Union Member? If Union Member, name of Union: Description of Job Duties: Work Overtime? If yes, paid at time-and-a-half? Terminated or Laid Off from Work? If yes, please explain: Interested in returning to the same job? If necessary, are you interested in a modified job with the same employer? Do you know if your employer would consider job modification? Did you complete a Workers Compensation Claim Form and give it to your employer?

2 If yes, what date did you give the claim form to your employer: Also, bring a copy to consultation. Did your employer answer (complete the bottom portion of the claim form) and return a copy to you marked Employee s Copy? Have you given a statement about your injury to anyone other than your doctor? If yes, please identify: Other Employment Did you have a second job at the time of injury? Do you have a second job now? Current Employer: If working, date of return to work: If not working, date last worked: Other employer in past year: Job Title: Pay Rate: Date of Hire: Hours Per Week: Injury/Illness Information Have you consulted another attorney about this injury/illness prior to today? Date of injury/illness (if more than one date, please list): Place of injury/illness: Type of injury/illness: Parts of body injured: How did the injury/illness happen? Responsibility for injury/illness (check all that apply): Employer Co-worker Chemical Substance Machinery Unsafe Condition Someone else Please explain if you checked one or more of the above: Medical Treatment for Injury/Illness Below, please list present treating doctor(s), date(s) last seen, and the nature of the treatment.

3 Doctor: Doctor: Below, please list all other doctors/hospitals seen for the injury/illness. Doctor: Doctor: Were you hospitalized overnight for the injury/illness: Who do you believe is your treating doctor? Was the doctor selected by your employer? Before the date of injury/illness, did you give your employer the name of a doctor to treat you? Do you have objections to changing to a doctor of our choice? Insurance Information Insurance Company: Claim Number:

4 Adjuster: Do you have health insurance: Telephone: If yes, name: Who paid/is paying for your medical treatment (check all that apply)? Workers Comp Insurance Company Private health insurance Medi-Cal Yourself Below, please list all unpaid medical bills related to the injury/illness, and all medical bills paid by you for which you have not been reimbursed. Unpaid Paid (But Not Reimbursed) Information for Calculation of Disability Benefits* Periods you did not work due to this injury/illness: Periods you received workers compensation benefits: Have you applied for State Disability Insurance (SDI): Below, please list the benefits received, if any, from other sources. State Disability Insurance Date: Amounts: Unemployment Date: Amounts: Social Security Date: Amounts: Long-Term Disability Date: Amounts: Retirement/Pension Date: Amounts: IDL (State Employees Only) Dates: Amounts:

5 NDI (State Employees Only) Dates: Amounts: Other: Dates: Amounts: *Bring a copy of last two (2) years W2 forms (years prior to injury/illness). *Bring a copy of your last pay stub prior to injury/illness. Other Injuries/Illnesses Have you ever had any other on the job injuries/illnesses? Dates Parts of Body Injured How it Occurred Fully Recovered Have you ever had any other off the job injuries/illnesses? Dates Parts of Body Injured How it Occurred Fully Recovered Below, please list the names, addresses, and dates of all doctors/hospitals seen for each of the above injuries/illnesses (use an extra sheet of paper if additional space is needed). Dates Doctors/Hospitals Address Have you ever filed a claim or lawsuit for a work injury or personal injury? If yes, please explain: Please list any other medical conditions (e.g., heart disease, arthritis, emphysema, osteopenia, etc.):

6 Below, please list the names, addresses, and dates of all doctors/hospitals seen for each of the above injuries/illnesses (use an extra sheet of paper if additional space is needed). Dates Doctors/Hospitals Address TO BE COMPLETED BY ATTORNEY Third Party? Serious & Willful? 132a? Discussed? Discussed? Discussed?