WORKER’S COMPENSATION HISTORY

Name _________________________________ Age ____ Date of Birth ___________   □ Male  □ Female

Address _______________________________ City _________________ State ________ Zip _________

SS # _______________________________________ Driver’s Lic. # ______________________________

Employer’s Name __________________________________ Tel # _______________________________

Address _______________________________ City _________________ State ______ Zip ___________

Carrier’s Name ___________________________________ Tel # _________________________________

Address _________________________________ City ________________ State ______ Zip __________

Have you retained legal counsel for this injury?   Yes   No   If “Yes”, give name and address:

___________________________________________________________________________

INJURY DESCRIPTION

Date present injury was received ________ Time Injury ______ □ AM   □ PM  Overtime?   □ Yes   □ No

Who saw the accident?   Name __________________________ Title _____________________________

Who reported the accident?  Name ___________________________ Title _________________________

What medical attention was rendered? ______________________________________________________

By whom?   □ Nurse   □ M.D.   □ D.O.   □ D.C.   □ Other employee   □ Other ____________________

How did the injury occur? ________________________________________________________________

Chief Complaint ________________________________________________________________________

Symptoms ____________________________________________________________________________

Since the injury, are your symptoms    □ Improving   □ The Same   □ Getting Worse

If working on a machine, give description ___________________________________________________

Do you use foot or hand levers?   □ Yes   □ No   Do you work overhead?   □ Yes   □ No 

Do you have to reach?   □ Yes   □ No   Where? ______________________________________________________

Movements on the job: Do you move to your   □ Right   □ Left   □ Up   □ Down   □ Under   □ Over

Do you pick up or lift?   □ Yes   □ No  If “Yes”, how much? _____________ How often? _____________

From where to where? __________________________

Do you lift from   □ Ground   □ Bench   □ Platform   □ Box   □ Pallet   □ Other (Please describe) _____________________________________________________________

Do you lift in or out of a machine?  □ Yes  □ No 

If working at a machine, do you  □ Sit  □ Stand  □ Kneel

Is your work area cluttered?   □ Yes   □ No   If “Yes”, with what? _____________________________________________________________

Is your work area   □ Oily   □ Dirty   □ Slippery   □ Other _____________________________________________________________

In your job do you push or pull?   □ Yes   □ No    If “Yes”, give specifics _____________________________________________________________

Do you use a cart?  □ Yes  □ No  □ Two-wheel  □ Four-wheel

Types of wheels   □ Rubber   □ Steel   □ Plastic

Condition of cart   □ Good   □ Bad    □ Other_______________  

Number of carts being pushed or pulled at once______

Total amount of weight being pushed or pulled on a daily basis ________________________________

OFFICE WORK

If your injury has occurred from office work only, please fill out the following:

□ Sit at desk   □ Walk   □ Stand   □ Stoop   □ Hold   □ Carry   □ Other ________________________

Give percentage if applicable __________________ Do you operate office machinery?   □ Yes   □ No 

If “Yes”, what type? ___________________________________________________________________

If you work is at a desk, give specifics of job, computer, typewriter, business machines, phone, etc. __________________________________________________________________________________

If walking, where to and job classification __________________________________________________________________________________

Do you carry anything or pick anything up?   □ Yes    □ No    If “Yes”, what? __________________________________________________________________________________

PREVIOUS WORK HISTORY

Give a job description of services or work performed for each job classification or source of employment for the preceding ten (10) years.

1. ___________________________________________________________________________________

2. ___________________________________________________________________________________

3. ___________________________________________________________________________________

4. ___________________________________________________________________________________

5. ___________________________________________________________________________________

Was a pre-employment exam performed or required?   □ Yes   □ No

Date _________________ Doctor _______________________ Place ____________________________

Have you ever applied for Workers’ Compensation before?   □ Yes   □ No      Date _________________

Reason ______________________________________________________________________________

Was there a time loss from work?   □ Yes   □ No   From _________ To _________ Year _________

Did you retain legal counsel for these injuries?   □ Yes   □ No   If “Yes”, give name and address ____________________________________________________________________________________

PRESENT WORK HISTORY

What is the job classification of your normal job? __________________________________________________________

Were you performing your normal job?   □ Yes   □ No   

What shift were you working? ____________________________

How long have you been at your present job? ___________________

Has there been a time loss or absenteeism caused from job injury?    □ Yes   □ No   If “Yes”, explain __________________________________________________________________________________

Average work week _________________________ Hours ______________________Days

 JOB CONDITIONS

Type of building ______________________________________________________________________

Type of floor   □ Rough   □ Smooth   □ Wood   □ Concrete   □ Steel   □ Other ___________________

Type of windows   □ Open    □ Closed    □ No windows

Type of ventilation in the building  

□ Blower   □ A/C   □ Heat   □ Exhaust    □ None   □ Other _____________________

Type of lighting in the building  

□ Fluorescent    □ Overhead    □ On machine     □ Other _________________________

Are you tired when you go home at night?   □ Yes    □ No  

Do you have any outside jobs?   □ Yes    □ No    If “Yes”, what type? _________________________________________

Do you participate in any company-sponsored programs such as exercise, sports, etc?  □ Yes   □ No

If “Yes”, describe ___________________________________________________________________________________

Type of shop     □ Union     □ Non-union

Has outside help been hired?   □ Yes   □ No    If “Yes”, why? _________________________________

How many employees are in the plant? ________ How many employees per shift? __________

How many employees do your job? _______ What is the current injury ratio for that job? _________

How many employees have been injured doing your job? _______ Do you like your job?  □ Yes  □ No

If off work, do you want to return to your job?    □ Yes  □ No

What changes would you make in your job? ______________________________________________________________________________________

______________________________________________________________________________________

___________________________________________________________     ________________________

Patient Signature                                                                                                                                 Date

___________________________________________________________     ________________________

Staff Signature                                                                                                                                     Date