Workers Compensation Forms：工人补偿形式.doc

WORKERS COMPENSATION HISTORYPLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU.Patients Name:_ Date:_Address:_ City:_State:_ Zip:_ Home Phone:_ Work Phone:_Social Security #:_ Driver Lic # _Date of Birth:_ Age:_ Sex: F M Right/Left HandedHeight:_ Weight:_ Smoker:_ Married: Y NNearest Relative:_ Phone:_ INJURY INFORMATIONDate of Injury:_ Time of injury:_Employer at time of injury:_Date of hire:_ Length of time worked:_Date Claim Filed:_ Last Date of Employment:_Please list all body parts injured:_Prior to the date(s) above have you ever injured the same area(s) of your body?_Did you have a pre-employment physical examination? Yes NoAny work restrictions based on that exam? Yes No Explain:_Describe how the injury happened: (Did you fall, were you struck by something, were you in an auto accident, were you using special equipment, etc)Describe what part of your body was injured in the accident:_What kind of pain or discomfort did you experience at the time of injury?_Page 2Did you report the accident at the time of injury? Yes No If so to whom?_Were there any witnesses to the accident, if so, who?_ PAST MEDICAL TREATMENTWhat occurred immediately after the accident? (Were you provided with medical treatment, etc.)_Did you go to a hospital? Yes No Clinic? Yes No When?_ If you did not seek or receive medical treatment immediately following the incident, when, and for what reason, did you first seek or receive medical care? _Name of Doctor: _ M.D. D.O. Chiropractor?Treatment: _Frequency and duration of the treatment: _Who referred you to the Doctor/Chiropractor? _Did you see any other doctors/chiropractors prior to presenting to our office? _Name of Doctor: _ Date seen: _Type of treatment rendered:_ CURRENT TREATMENTName of Doctor:_ Diagnosis: _Treatment rendered: _Chiropractors Name: _ Diagnosis: _Treatment: _Who referred you to Chiropractor: _How long is each treatment:_ How often: _ Is it helping? _ How long have you been treating? _PHYSICAL THERAPY: What does the therapist do for treatment? _How long is the treatment? _ How often? _ Does it help?WC HISTORYFollowing your first medical care, did you see any other doctors or undergo any special Page 3Tests? MRI, CT SCAN, X-RAY If so, please list the doctor or facility visited and briefly state why you saw them (referred by someone else or due to pain and discomfort, etc) What were the findings on the tests? _ CURRENT COMPLAINTS? _What did the doctor say was wrong with you? _ What makes the pain better? _What makes the pain worse? _When or how often do you experience pain? _ PAST MEDICAL HISTORYPersonal doctor/chiropractor: _City: _ Phone: _Your personal doctor has treated you for the following: PLEASE LISTDo you have or have you ever had any of the following (Please circle)Alcoholism Y N Gout Y NAnemia Y N Heart trouble Y NArthritis Y N High Blood pressure Y NEdema (swelling) Y N Kidney disease Y NBleeding disorder Y N Liver disease Y NCancer Y N Mental Illness Y NDiabetes Y N Migraine headaches Y NEmphysema Y N Stomach ulcers Y NEpilepsy Y N Stroke Y NGlaucoma Y N Tuberculosis Y NDrug Abuse Y N HIV Aids virus Y NOther serious diseases _Previous motor vehicle accidents _ Date: _Previous Work Comp accidents _ Date: _Previous wounds/burns _ Date: _WC HISTORY Page 4Orthopeadic problems (describe) _Operations (please circle)Appendix Y N Date/Age: _Gallbladder Y N Date/Age: _Hernia Y N Date/Age: _Hysterectomy Y N Date/Age: _Stomach Y N Date/Age: _Tonsils Y N Date/Age: _Other operations or surgeries: _ Have you been hospitalized for any other problems? Please describe: _Do you have any other claims or suits pending? Yes No Explain: _Are you currently taking ANY medications? Please list: _Are you allergic to any medications? Please list: _How and when did you discover you had allergic problems? _ FAMILY HISTORYFather: Alive / Deceased Age: _ Health: _Mother: Alive / Deceased Age: _ Health: _Do you have brothers? Yes No How many? _ Health: _Do you have sisters? Yes No How many? _ Health: _ PERSONAL & SOCIAL HISTORYDo you smoke? Yes No If so, how much? _ Since: _Do you drink? Yes No If so, who often? _ Since: _Do you drink Wine? _ Beer? _ Hard Liquor? _Marital status (circle) SINGLE MARRIED DIVORCED WIDOWED SEPARATEDChildren? _ How many? _ Ages: _Country of birth: _ How long in the U.S.? _WC HISTORY Page 5Highest level of education: _Completed _ Grade _ Year _Military history: Branch _ Date entered _ Date discharged _Type of discharge: _ OCCUPATIONAL HISTORYEmployer at the time of injury _Date of Hire: _ Job title: _Work hours: _ to _ Days: M T W Th F S SunWork restrictions when hired? Yes No If so, please list: _Are you presently working for the same company where you were injured? Yes NoIf not, when did you leave your employer? _ Why? _If you have a new employer, what is your current job description? _Employers name: _ Location? _When did you start the new job? _What are your physical duties at the new job? _ Are you full time? Yes No Part time? Yes NoAny restrictions? Yes No What are they? _If you are not presently working, are you seeking a new job? _How long have you been off work? _Who advised you to be off work? _If you are on medical leave, when are you expected to return to work? _List employer(s) and dates of employment BETWEEN the job in which you injured yourself and your current employer: _Do you feel you are able to return to work? Yes No In what capacity?PAST EMPLOYERSEmployer Dates worked Job title Injured1._2. _WC HISTORY Page 63. _PLEASE NOT THE FOLLOWING INFORMATION PERTAING TO THE SPECIFIC JOB REQUIREMENTS AT THE TIME OF INJURYGeneral job description at the time of injury: _Divide you typical 8 hour day into SITTING, STANDING, and WALKINGSITTING 1 2 3 4 5 6 7 8 HoursSTANDING 1 2 3 4 5 6 7 8 HoursWALKING 1 2 3 4 5 6 7 8 HoursNOTE: OCCASIONAL 33% of the time FREQUENTLY 33-66% of the time CONTINUOUS 66-100% of the timeYou were required to lift: NEVER OCCAS FREQ. CONTINUOUSUp to 10 pounds _ _ _ _11 to 20 pounds _ _ _ _21 to 50 pounds _ _ _ _51 to 100 pounds _ _ _ _You were required to lift and carry: NEVER OCCAS FREQ CONTINUOUSUp to 10 pounds _ _ _ _11-20 pounds _ _ _ _21-50 pounds _ _ _ _51-100 pounds _ _ _ _ WC HISTORY PAGE 7You were required to use your hands for repetitive action such as: FINE MANIPULATION SIMPLE GRASPING PUSHING/PULLINGRIGHT YES NO YES NO YES NO LEFT YES NO YES NO YES NOYou were required to use your feet in repetitive movements (as in operating foot controls) RIGHT: YES NO LEFT YES NOYou were required to: NEVER OCCAS FREQ CONT