FEDERAL INJURY CENTERS

DOL NEW PATIENT INFORMATION SHEET
FULL NAME

First NameLast Name
TODAY'S DATE

MonthDayYear
Date
DATE OF INJURY

MonthDayYear
Date
PATIENT ACCOUNT #
HOME PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
CELL PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
EMAIL ADDRESS
example@example.com
HOME ADDRESS
HOW DID YOU HEAR ABOUT US?
DATE OF BIRTH
SSN#
INJURED BODY AREA
EMPLOYER (AGENCY)
EMPLOYER ADDRESS
EMPLOYER PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
SUPERVISOR'S FIRST AND LAST NAME
WHAT IS YOUR CRAFT?
CASE #
CLAIM EXAMINER'S FIRST AND LAST NAME
CLAIM EXAMINER'S PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
HAVE YOU FILLED OUT A CA1 or CA2? (SELECT THE ONE THAT APPLIES) PLEASE PROVIDE COPY

CA-1CA-2
DID YOUR SUPERVISOR GIVE YOU A CA-17 (DUTY STATUS REPORT) TO BRING WITH YOU?

YESNO
DID YOUR SUPERVISOR GIVE YOU A CA-16 (AUTHORIZATION FOR MEDICAL TREATMENT) TO BRING WITH YOU?

YESNO
TREATING DOCTOR'S NAME
TREATING DOCTOR'S PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
HAVE YOU HAD THERAPY?

YESNO
IF YES, HOW MUCH AND WHEN?
HAVE YOU HAD SURGERY?

YESNO
IF YES, WHEN DID YOU HAVE SURGERY?
PATIENT QUESTIONNAIRE

FOR TRAUMATIC INJURIES: JUST ANSWER QUESTION 1. FOR REPETITIVE INJURIES: ANSWER QUESTIONS 1 & 2
1. DESCRIBE IN DETAIL THE EMPLOYMENT RELATED ACTIVITIES WHICH YOU BELIEVE CONTRIBUTED TO YOUR CONDITION.
2. WHEN DID YOU FIRST NOTICE IT? HAS IS COME AND GONE, OR HAS IT BEEN PRESENT CONTINUOUSLY? WHAT SYMPTOMS HAVE YOU EXPERIENCED?
3. HOW OFTEN DID YOU PERFORM THE ACTIVITIES DESCRIBED? FOR HOW LONG ON EACH OCCASION?
4. STATE WHERE YOU WERE AND WHAT YOU WERE DOING AT THE TIME OF YOUR INJURY OCCURRED. PROVIDE A DETAILED DESCRIPTION AS TO HOW YOUR INJURY OCCURRED. FOR EXAMPLE, IF YOU FELL, STATE HOW YOU FELL AND LANDED ETC.. IF LIFTING WAS THE CAUSE OF THE INJURY, DESCRIBE THE OBJECT HANDLED, ITS WIEGHT, WHAT YOU DID WITH IT ETC.
5. PROVIDE STATEMENT FROM ANY PERSON WHO WITNESSED YOUR INJURY OR HAD IMMEDIATE KNOWLEDGE OF IT OR OTHER DOCUMENTATION THAT SUPPORTS YOUR CLAIM.
6. STATE THE IMMEDIATE EFFECTS OF THE INJURY AND WHAT YOU DID IMMEDIATELY THEREAFTER.
7. DID YOU SUSTAIN ANY OTHER INNJRY, EITHER ON OR OFF DUTY, BETWEEN THE DATE OF THE INJURY AND THE DATE IT WAS FIRST REPORTED TO YOUR SUPERVISOR AND TO A PHYSICIAN?
Should be Empty:

DOL NEW PATIENT INFORMATION SHEET

PATIENT QUESTIONNAIRE