Re-exam IME quesionnaire

Name* This field is required.

First Name

Last Name

Date of Birth* This field is required.

Date

Please describe what treatments you have had since your last IME with us:* This field is required.

What is your greatest concern at this time?* This field is required.

Where is your pain located?* This field is required.

How would you describe your pain?* This field is required.

What makes your pain worse?* This field is required.

What makes your pain better?* This field is required.

How frequent is your pain?* This field is required.

We would like to ask you about your pain . In answering these questions: 0 is pain free ....1 – Pain is very mild, barely noticeable. Most of the time you don’t think about it.....* This field is required.

Do you have any of the following conditions? Select all that apply* This field is required.

Depression or PTSD

Use Opiods

Diabetes

Obesity

Substance Abuse

High Blood Pressure

Smoker

I had surgery for this problem

I have been in the hospital for this problem

I have hired an attorney for this case

None of the above apply to me

What is the name of your employer?* This field is required.

How long have you been working for that employer?* This field is required.

Are you still working for the same employer?* This field is required.

YESNO

What is your job title?* This field is required.

What is your job description?* This field is required.

Please tell us your Weight (lbs) and Height (feet and Inches)* This field is required.

Please list any tasks that are difficult for you to perform:* This field is required.

What type of work have you performed previously?* This field is required.

What is your level of education?* This field is required.

Are you working now (Please describe if applicable)?* This field is required.

Has your doctor, or anyone, prescribed any work restrictions? If yes please describe:* This field is required.

Where do you live?* This field is required.

Who lives with you?* This field is required.

Please describe your typical day:* This field is required.

Please describe any significant recreational pursuits you are involved with:* This field is required.

Do you smoke?* This field is required.

YESNO

How many alcoholic beverages do you have per week?* This field is required.

Please list any medical hospitalizations:* This field is required.

Please list any operations you have had since you last IME:* This field is required.

Please list any medications you are currently taking:* This field is required.

Please list any medication allergies that you have:* This field is required.

Have you had any other medical problems?* This field is required.

Please provide any other comments that may assist us in understanding your situation:* This field is required.

Please upload any files to help us better understand your case. These may include photographs taken around the time of injury or anything else you would like to show us.

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Select files to upload

Max. file size: 10.6MB

Please list the names of anyone who helped you fill out this form* This field is required.

I understand that I am being seen for an independent medical evaluation and no treating physician/patient relationship is established. I understand that the information I discuss will be included in a report that is prepared for the requesting client:

YESNO

Sign and acknowledge the previous statement. Please type full name in text box.* This field is required.