WORK/COMP HISTORY
Name:
Date of Accident:
-
Month
-
Day
Year
Date
1. Name of employer at time of accident:
2. Length of time worked there prior to accident:
3. Type of work being done at time of injury:
4. In your own words, please describe accident:
Have you been treated by another doctor for this accident?
Yes
No
If yes, please list doctor's name and address:
What type of treatment did you receive?
How long were you treated by this doctor?
6. Are you:
Improved
Changed
Getting worse
7. What types of medicines are you taking?
Does these medicines help?
Yes
No
Don't Know
8. Have you had physical therapy?
Yes
No
If yes, how often:
Daily
Every other day
Several times a week
Weekly
Every other week
Monthly
Have you had physical therapy?
Yes
No
Don't know
9. Prior to this accident, have you ever had any of the physical complaints similar to what you have now?
Yes
No
Don't know
If yes, describe:
Were these similar complaints the results of a previous accident(s)?
Yes
No
Please provide details of accident(s):
10. Have you had any other serious accidents which required medical care?
Yes
No
Describe:
11. Have you had any serious illnesses that required hospitalization?
Yes
No
Describe:
12. Have you had any surgeries?
Yes
No
If yes, please list type of surgery and date:
13. Have you had any nervous or mental illnesses?
Yes
No
Have you had psychiatric care?
Yes
No
14. Have you received a medical discharge from the Armed Forces?
Yes
No
15. Have you returned to work since this accident?
Yes
No
If you have returned to work since your accident, please fill out the information below:
Back
Next
CURRENT MEDICAL COMPLAINTS
BACK PAIN:
1. Currently, I have pain in my:
Low back
Mid back
Upper back
2. My pain began:
Gradually
Suddenly
3. I have pain:
Sometimes
All of the time
4. My pain goes into my:
Right leg
Left leg
Both
5. I have tingling and/or numbness in my:
Right leg
Left leg
Both
6. My pain is worse when l:
Rows
Yes
No
Cough or sneeze
Sit
Bend
Walk
Push
7. My back is worse with sexual activity
Yes
Nos
8. My pain wakes me up during the night
Yes
No
9. Changes in the weather affect my pain
Yes
No
NECK PAIN:
1. My neck pain began:
Gradually
Suddenly
2. I have pain:
Sometimes
All of the time
3. My pain goes into my:
Right leg
Left leg
Both
4. I have tingling and/or numbness in my:
Right leg
Left leg
Both
5. My pain is worse when l:
Rows
Yes
No
Cough or sneeze
Bend forward
Push
Pull
Turn my head
6. My pain wakes me up during the night
Yes
No
7. Changes in the weather affect my pain
Yes
No
8. I have neck stiffness
Yes
No
9. I have headaches
Yes
No
10. If I do get headaches, they occur:
Sometimes
All of the time
OTHER PAIN
Please describe any current medical complaints which you are experiencing and were not previously covered on this questionnaire, or list any additional comments you wish to make regarding your condition:
JOB DESCRIPTION:
(In terms of an 8-hour workday, "occasionally" means 33%, "frequently" means 34% to 66%, and "continuously" means 67% to 100% of the day).
1. In a typical 8-hour workday, (Select # of hours/activity)
Rows
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours
7 hours
8 hours
Sit
Stand
Walk
2. On the job, I perform the following activities:
Rows
NOT AT ALL
OCCASIONALLY
FREQUENTLY
CONTINUOUSLY
Bend/stoop
Squat
Crawl
Climb
Reach above shoulder level
Crouch
Kneel
Balancing
Pushing/Pulling
3. On the job, I lift:
Rows
NOT AT ALL
OCCASIONALLY
FREQUENTLY
CONTINUOUSLY
Up to 10 pounds
11 to 24 pounds
25 to 34 pounds
35 to 50 pounds
51 to 74 pounds
75 to 100 pounds
4. Do you have to bend over while doing any lifting?
Yes
No
5. Are your feet used for repetitive movements, such as in operating foot controls?
Yes
No
6. Do you use your hands for repetitive actions, such as:
Rows
SIMPLE GRASPING
FIRM GRASPING
FINE MANIPULATING
Right Hand
Yes
No
Yes
No
Yes
No
Left Hand
Yes
No
Yes
No
Yes
No
7. Are you required to work on unprotected heights?
Yes
No
Describe:
8. Are you required to be around moving machinery?
Yes
No
Describe:
9. Are you exposed to marked changes In temperature and humidity?
Yes
No
Describe:
10. Are you required to drive automotive equipment?
Yes
No
Describe:
11. Are you exposed to dust, fumes and/or gases?
Yes
No
Describe:
12. Please list any additional comments:
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: