Workers Compensation Form



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Transcription:

Workers Compensation Form Patient Name: Job Title: Employer: What is your current work status? Working full duty Off work due to injury, since: Working light or modified duty Other: Does your job require frequent lifting or carrying? What is the approximate maximum weight you have to lift? lb. Is your job physically demanding? Does your job require constant repetitive activity? Does your job require strong or repetitive gripping with your hands? How much of your job do you believe you can perform at this time? Some All ne Date of injury or Onset of Symptoms? What area of your body did you injure? How were you injured? Have you had this type of injury before? How many times? Have you had physical therapy for this problem before? Have you undergone any diagnostic test for this? (x rays, MRI, nerve condition test, blood tests) If yes, please list: Does coughing or sneezing reproduce your pain? Have you recently had problems with your bladder or bowel? Please grade the amount of pain you have today (circle one) 0 1 2 3 4 5 6 7 8 9 10 Please indicate on the diagram below where your pain or symptoms are: What makes your pain or symptoms feel better? What make your pain or symptoms worse?

Medical History (Please circle one) Do you have high blood pressure? Do you have heart disease? Do you experience angina (chest pain)? Do you experience shortness of breath? Do you have lung disease? Do you have a history of cancer? Do you experience heartburn or stomach upset? Do you have a thyroid condition? Have you experienced recent weight loss/gain? Do you have diabetes? Do you have low blood sugar? Have you experienced an increase in frequency or intensity of headache? Do you have unusual joint pain and/or swelling? Do you have a history of fractures? Do you have osteoporosis? Do you have impaired hearing? Do you have impaired vision? OB/GYN (circle one) Are you now, or do you have any reason to believe you may be pregnant? Have you had any complicated pregnancies? Have you had pelvic inflammatory disease? Do you have dysmenorrhea (abnormal menstrual cycle)? Please list ALL medications, dosage and purpose: Please list all surgeries and dates: Have you seen anyone else for your current problems? If so please explain: This questionnaire is used to assist us in having a better understanding of your overall health status and is part of your confidential medical record. Please discuss any concerns regarding the questionnaire with the therapist. Signature: Date:

1. Are you currently working? Physical Job Demand 2. How many hours a week are you currently working? 3. Is this your normal amount of work hours? 4. How many hours a week do you normally work? 5. Are you currently performing your full duties as work? 6. Are you on modified duty? If yes, what are your restrictions? 7. Does your company offer modified duty? 8. How would you rate the overall demand of your work? (Check one) Sedentary Heavy Light Very Heavy Medium 9. How often do you lift weight from the floor during your workday? (Check one) 9a. What is the average weight you lift from the floor? 9b. What is the maximum weight you lift from the floor? 10. How often do you lift overhead during your work day? (Check one) 10a. What is the average weight you lift overhead? 10b. What is the maximum weight you lift overhead? 11. How often do you push/pull objects during your work day? (Check one)

11a. What is the average weight you push/pull? 11b. What is the maximum weight you push/pull? 11c. What do you have to push/pull? 12. How often do you carry weight during your work day? (Check one) 12a. What is the average weight you carry? 12b. What is the maximum weight you carry? 12c. On average, how far do you carry objects? 13. How often do you reach overhead for prolonged periods during your work day? 13a. Please explain these activities: 14. How often are you sitting during your work day? (Check one) 15. How often are you standing during your work day? (Check one) 16. How often are you walking during your work day? (Check one) 17. How often do you climb stairs during your work day? (Check one)

18. How often are you at a computer during your work day? (Check one) 19. How would you describe the pace of your work? (Check one) Slow Steady Fast 20. Do you do repetitive tasks with your arms/hand during your work day? 21. Do you have to squat/crouch repetitively during your work day? 22. Do you have to be in a bent forward position for prolonged periods? 23. Does your job require you to twist often? 24. How much of your job do you believe you can perform at this time? ne of the duties Some of the duties All of the duties 25. What is your major concern, if any, with performing your job at this time? The information provided is an estimate of my performance at work, however to the best of my ability, the information is accurate. Signature Date

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