DOL New Patient Information

DOL New Patient Information
Please select a clinic location

Federal Injury Centers of FL (Dunedin)Federal Injury Centers of USA (Ocala)Federal Injury Doctors (St. Petersburg)DOL Doctors of Tampa Bay (Tampa)Federal Injury Mental Health (Telemedicine)
Today's Date

MonthDayYear
Date
Patient Case Number, if known
Name

First NameLast Name
Date of Injury

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Social Security Number
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Spouse/Significant Other Name
Patient Spouse/Significant Other Number
Please enter a valid phone number.
How Did You Hear About Us?
Injured Body Area(s)
Employer (Agency)
Employer's Phone Number
Please enter a valid phone number.
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 A CA-1 or CA-2?
If so, please provide3 a copy at the time of your appointment.
Did Your Supervisor Give You a CA-17 (Duty Status Report) to Bring With You?
Did Your Supervisor Give You a CA-16 (Authorization for Examination/Medical Treatment)?
Have You Had Any Previous Therapy for This or Any Other Issue?

YesNo
If so, at which doctor's office or facility did you receive your therapy?
Have you had any surgery?

YesNo
If so, when?
Do you have any other injuries we can help you with?
Medical Evaluation Questionaire
1. Name

First NameLast Name
2. Date of Birth

MonthDayYear
Date
3. Are you

Right-handedLeft-handedEither
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?

YesNoNot sure
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?

YesNoNot sure
If yes, please describe.
7. Please describe how your current injury occurred.
8. What problems did you have following your current injury?
9. What did you do following the injury?
10. Have you had any additional injuries 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?

Constant (present 75% of the time or more)Frequent (present 50% to 75% of the time)Occasional (present 25% to 50% of the time)Infrequent (present less than 25% of the time)
17 A.) On a scale from O (no pain) to 10 (excruciating pain): 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
17 B.) On a scale from O (no pain) to 10 (excruciating pain): 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
17 C.) On a scale from O (no pain) to 10 (excruciating pain): 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
17 D.) On a scale from O (no pain) to 10 (excruciating pain): 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)?

YesNoNot sure
If yes, please describe the difficulties in detail.
19. Are there any tasks that are difficult for you to perform?

YesNoNot sure
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?

YesNoNot sure
Can you lift a heavy bag of groceries?

YesNoNot sure
Can you lift a pail of water?

YesNoNot sure
How long can you sit for at one time?
How long can you stand for at one time?
How long can you walk for at one time?
20. How long had you been working there?
21. What was your job title?
22. What activities did this job involve?
23. What type of work have you performed previously?
24. Have you had any other jobs since your injury? If yes, please describe.
25. Are you working now?

YesNo
If yes, please describe your current job. If no, when did you last work?
26. Has your doctor, or anyone, prescribed any work restrictions?

YesNoNot sure
If yes, please describe those restrictions.
27. Where do you live?
28. Please describe your typical day.
29. Are you currently involved in any significant physical activities or recreational pursuits?

YesNoNot sure
If yes, please describe.
Have you ever been involved in any significant physical activities or recreational pursuits?

YesNoNot sure
If yes, please describe.
30. Do you smoke/vape?

NoYes, in the past but I quitYes
If yes, how many packs a day?
31. How many alcoholic beverages do you have per week?
32. Have you had any medical (not surgical) hospitalizations?
33. Have you had any operations? (surgery)
34. Are you taking any prescribed medications?
35. Are you allergic to any medications?
36. Have you had any other medical problems?
37. Do you have any history of disease in your family?
38. 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.*

Yes
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DOL New Patient Information

Medical Evaluation Questionaire