DOL New Patient Information

DOL New Patient Information
Please select a clinic location
Today's Date:

MonthDayYear
Date
Full Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Patient Case Number, if known
Case Number
Date of Injury:

MonthDayYear
Date
Social Security Number:
Please include dashes (-)
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:
example@example.com
What is your current address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Spouse, Significant Other or Emergency Contact Name:
Patient's Spouse, Significant Other or Emergency Contact Number:
Please enter a valid phone number.Format: (000) 000-0000.
How Did You Hear About Us?
Referral, social media, google search, etc.
Injured Body Area(s):
Please describe your work-related injury or injuries
Employer (Agency):
Which agency were you working for at the time of your injury?
Employer's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Employer (Agency)'s Email Address:
example@example.com
Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor's Name:

First NameLast Name
What is your Craft?
Employee ID Number (EIN):
Have you filed out a CA-1 or CA-2? If so, please provide a copy at the time of your appointment.
Did your supervisor give you a CA-17 (Duty Status Report)? If so, please provide a copy at the time of your appointment.
Did your supervisor give you a CA-16 (Authorization for Examination/Medical Treatment)? If so, please provide a copy at the time of your appointment.
Have you been to an Emergency Room or other medical provider for this injury??
If so, where and when?
Have you had any previous therapy for this or any other issue?
If so, at which doctor's office or facility did you receive your therapy?
Have you had any surgery?
If so, when?
Do you have any other work-related injuries we can help you with?
Do you have any other concerns or questions we can help you with?
Medical Evaluation Questionaire
1. What is your full legal name?

First NameLast Name
2. Date of Birth:

MonthDayYear
Date
3. Are you:
4. When is the date of your injury?

MonthDayYear
Date
5. Have you ever had any previous problems or injuries, including any other work, recreational, or motor vehicle accidents?
If yes, please describe.
6. Have you ever had any difficulties prior to the date of your injury which were similar to those you are now experiencing?
If yes, please describe.
7. Please describe how your current work-related injury occurred.
8. What problems did you have following your current work-related injury?
9. What did you do following the work-related injury?
10. Have you had any additional WORK or NON-WORK injuries related since the date of injury in question #4?
11. What is your greatest concern at this time?
If you are not having difficulty with pain, please proceed to question #18.
12. Where if your pain located?
13. How would you describe your pain? (achy, burning, sharp, dull, tingling, etc)
14. What makes your pain worse?
15. What makes your pain better?
16. How frequent is your pain?
17. For the following questions, please do your best to rate your current pain on a scale from 0 (no pain) to 10 (excruciating pain):
17a. What number would you put on your pain at this time?

1

2

3

4

5

6

7

8

9

10

1 is Less Pain, 10 is More Pain
17b. During the past month, what has it averaged?

1

2

3

4

5

6

7

8

9

10

1 is Less Pain, 10 is More Pain
17c. During the past month, what is the highest it has been?

1

2

3

4

5

6

7

8

9

10

1 is Less Pain, 10 is More Pain
17d. During the past month, what is the lowest it has been?

1

2

3

4

5

6

7

8

9

10

1 is Less Pain, 10 is More Pain
18. Are you having any other difficulties (numbness, weakness, headaches, anxiety, etc)?
If yes, please describe the difficulties in detail.
Tasks:
19. Are there any tasks that are difficult for you to perform?
If yes, please describe the tasks which are most difficult for you.
How much can you lift occasionally? (lbs)
Can you lift a gallon of milk?
Can you lift a heavy bag of groceries?
Can you lift a pail of water?
How long can you sit for at one time?
Number of minutes, hours, etc
How long can you stand for at one time?
Number of minutes, hours, etc.
How long can you walk for at one time?
Number of minutes, miles, etc.
20. Who were you employed by when you were injured?
Please list agency.
21. How long had you been working there?
Years, months, weeks, etc.
22. What was your job title?
23. What activities did this job involve?
24. What type of work have you performed previously?
25. Have you had any other jobs since your injury?
If yes, please describe.
26. Are you working now?
If yes, please describe your current job. If no, when did you last work?
27. Has your doctor, or anyone, prescribed any work restrictions?
If yes, please describe those restrictions.
28. Where do you live?
29. Describe your current household. Who lives with you? Do you have any dependents who rely on your care?
30. Please describe your typical day.
31. Are you currently involved in any significant physical activities or recreational pursuits?
If yes, please describe.
32. Have you ever been involved in any significant physical activities or recreational pursuits?
If yes, please describe.
33. Do you smoke/vape?
If yes, how many packs a day?
34. How many alcoholic beverages do you have per week?
35. Have you had any medical (not surgical) hospitalizations?
36. Have you had any surgical operations?
If yes, who was your surgeon or medical group that performed the surgery?
37. Are you taking any prescribed medications?
38. Are you allergic to any medications?
39. Have you had any other medical problems?
40. Do you have any history of disease in your family?
41. Please provide any other comments which may assist us in understanding your situation.
Thank you for your assistance. At the time of visit, we will review this information in detail.
Where is your pain now?

Mark the areas on your body where you feel the sensations described below using the appropriate symbol. Mark the areas where the pain is radiating as well as the source of the pain. Include all affected areas.

SYMBOLS

Aching ▲

Numbness =

Pins and Needles ⚫️

Burning ◼️

Stabbing *

Other 𝗫
Draw on Image
For the privacy of all patients, I will refrain from using my cell phone or earbuds during treatment and physical therapy sessions.
Signature
Should be Empty:

DOL New Patient Information

Medical Evaluation Questionaire

17. For the following questions, please do your best to rate your current pain on a scale from 0 (no pain) to 10 (excruciating pain):

Tasks: