Injury Details Form
Please complete this form prior to your review. The information provided will assist us in assessing your injury and conducting a thorough examination. Please be as detailed and accurate as possible.
Full Name
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First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Gender
*
Employer Details:
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Department/Position:
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Injury description (please provide a detailed account):
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Symptoms and Functional Limitations:
Please describe the initial symptoms experienced after the injury:
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How have these symptoms changed or progressed over time?
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Please describe any functional limitations or difficulties you have experienced because of the injury:
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Is it first incidence or recurrence of similar pain injury/condition/pain before, please describe:
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Could this be due to a non-work-related injury or activity:
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Medical Treatment:
Date of initial medical treatment:
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Month
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Day
Year
Date
Name of healthcare provider/providers:
Diagnosis or preliminary findings:
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Treatment received:
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Medications:
Physiotherapy, Chiropractor, Osteopathy, Remedial massage treatment details (Please describe where, who, what did they do, number of sessions, effectiveness):
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Have you had any previous injuries or medical conditions related to the affected area? If yes, please provide details:
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Work Impact:
Are you still working? If yes, has the injury affected your ability to perform your regular job duties?
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Have you made any modifications or accommodations to your work environment or duties because of the injury? If yes, please describe:
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Do you intend to return to same job:
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Yes
No
Occupational history:
Length of current employment:
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Functional demands of the work:
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Previous Jobs:
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Education/Qualifications
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Previous Claims:
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Sports and Hobbies:
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Any regular fitness activities prior to the injury:
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Other Medical conditions:
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Previous Surgeries:
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Routine Medications:
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Other Relevant Information (Please provide any additional information you believe is important for us to know regarding your injury) :
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Signature
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Date
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Month
-
Day
Year
Please verify that you are human
*
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Should be Empty: