Workers Compensation Injury Questionnaire

Name

First Last

Email

Birth Date:

Gender:

Male

Female

Your Occupation:

Cell Phone:

Worker's Comp. Insurance Company Information

Worker's Compensation Claim Number:

Name of Worker's Comp. Insurance Company:

Name of Claims Adjuster:

Phone # of Worker's Comp. Insurance Company:

Address Where to Send Claims:

Street Address Address Line 2 City State ZIP Code

Employer Information

Employer:

Phone # of Employer:

Type of Business:

Employer's Address:

Street Address Address Line 2 City State ZIP Code

Job Description:

In a typical 8-hour work day, how many hours do you sit:

In a typical 8-hour work day, how many hours do you stand:

In a typical 8-hour work day, how many hours do you walk:

On the job, I perform the following activities:

Balancing

Bend/Stoop

Climb

Crawl

Crouch

Kneel

Pushing/Pulling

Reach Above Shoulder Level

Squat

On the job, I lift:

Up to 10 pounds

11 to 24 pounds

25 to 34 pounds

35 to 50 pounds

51 to 74 pounds

75 to 100 pounds

100+ pounds

Do you have to bend over while doing any lifting?

Yes

No

Additional Comments

Worker's Comp. Insurance Company Information

Employer Information

Injury Information

Current Medical Complaints

Back Pain:

Neck Pain:

Other Symptoms:

Job Description:

On the job, I perform the following activities:

On the job, I lift: