Incident/Injury Description

Format: (000) 000-0000.

EMPLOYMENT/WORK HISTORY

Complete the information below for all employment/work since at least 5 years before your most recent injury starting with your most recent/current position.

MM/DD/YYYY - MM/DD/YYYY

LUMBAR SPINE: LOW BACK PAIN AND/OR LEG PAIN (OR ANY DISCOMFORT)

Tell us how you were BEFORE the incident. Place an "x" in the box of the best answer for each question. (Mark only one box for each question).

I have no pain/discomfort at the moment.The pain/discomfort is very mild at the moment.The pain/discomfort is moderate at the moment.The pain/discomfort is fairly severe at the moment.The pain/discomfort is very severe at the moment.The pain/discomfort is the worst imaginable at the moment.

I can look after myself normally without it causing extra pain.I can look after myself normally, but it causes extra pain.It is painful to look after myself and I am slow and careful.I need some help, but manage most of my personal care.I need help every day in most aspects of self-care.I do not get dressed, wash with difficulty, and stay in bed.

I can lift heavy weights without extra pain.I can lift heavy weights, but it gives extra pain.Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (i.e. on a table).Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.I can lift only very light weights.I cannot lift or carry anything at all.

Pain does not prevent me from walking any distance.Pain prevents me from walking more than 1 mile.Pain prevents me from walking more than 1/2 mile.Pain prevents me from walking more than 1/4 mile.I can only walk using a stick or ctuches.I am in bed most of the time, and have to crawl to the toilet.

I can sit in any chair as long as I like.I can only sit in my favorite chair as long as I like.Pain prevents me from sitting more than one hour.Pain prevents me from sitting more than thirty minutes.Pain prevents me from sitting more than ten minutes.Pain prevents me from sitting at all.

I can stand as long as I want without extra pain.I can stand as long as I want, but it gives extra pain.Pain prevents me from standing more than one hour.Pain prevents me from standing more than thirty minutes.Pain prevents me from standing more than ten minutes.Pain prevents me from standing at all.

Pain does not prevent me from sleeping well.I can sleep well only by using tablets.Even when I take tablets, I have less than six hours sleep.Even when I take tablets, I have less than four hours sleep.Even when I take tablets, I have less than two hours sleep.Pain prevents me from sleeping at all.

My normal homemaking/job activities do not cause pain.My normal homemaking/job activities increase my pain, but I can still perform all that is required of me.I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful activities (e.g. lifting, vacuuming).Pain prevents me from doing anything but light duties.Pain prevents me from doing even light duties.Pain prevents me from performing any job or homemaking chores.

My social life is normal, and gives me no extra pain.My social life is normal, but increases the degree of pain.Pain has no significant effect on my social life apart from limiting my energetic interests (e.g. dancing, etc.)Pain has restricted my social life, and I do not go out as often.Pain has restricted my social life to home.I have no social life because of pain.

I can travel anywhere without extra pain.I can travel anywhere, but it gives extra pain.Pain is bad, but I manage journeys over two hours.Pain restricts me to journeys less than one hour.Pain restricts me to short journeys under thirty minutes.Pain prevents me from traveling, except to the doctor or hospital.

CERVICAL SPINE: NECK PAIN AND/OR ARM PAIN (OR ANY DISCOMFORT)

Tell us how you were BEFORE the incident. Place an "x" in the box of the best answer for each question. (Mark only one box for each question).

I can read as much as I want to, with no pain in my neck.I can reach as much as I want to, with slight pain in my neck.I can read as much as I want to, with moderate pain in my neck.I can't read as much as I want because of moderate pain in my neck.I can hardly read at all because of severe pain in my neck.I cannot read at all because of pain in my neck.

I have no headaches at all.I have slight headaches, which come infrequently.I have moderate headaches, which come infrequently.I have moderate headaches, which come frequently.I have severe headaches, which come frequently.I have headaches almost all the time.

I can concentrate fully when I want to, without difficulty.I can concentrate fully when I want to, with slight difficulty.I have a fair degree of difficulty in concentrating when I want to.I have a lot of difficulty concentrating when I want to.I have a great deal of difficulty concentrating when I want to.I cannot concentrate at all.

I can do as much work as I want to.I can only do my usual work, but no more.I can do most of my usual work, but no more.I cannot do my usual work.I can hardly do any work at all.I cannot do any work at all.

I can drive my car without any neck pain.I can drive my car as long as I want with slight pain in my neck.I can drive my car as long as I want with moderate pain in my neck.I can't drive my car as long as I want because of moderate pain in my neck.I can hardly drive at all because of severe pain in my neck.I can't drive my car at all.

I have no trouble sleeping.My sleep is slightly disturbed (less than 1 hour sleepless).My sleep is mildly disturbed (1-2 hours sleepless).My sleep is moderately disturbed (2-3 ours sleepless).My sleep is greatly disturbed (3-5 hours sleepless).My sleep is completely disturbed (5-7 hours sleepless).

I am able to engage in all of my recreational activities with no pain at all.I am able to engage in all of my recreational activities with some pain in my neck.I am able to engage in most, but not at all of my recreational activities because of pain in my neck.I am able to engage in a few of my recreational activities because of pain in my neck.I can hardly do any recreational activities because of pain in my neck.I cannot do any recreational activities at all.

Incident/Injury Description

PRIOR TO INCIDENT

Prior Activities

WORK HISTORY