Workers Compensation Injury Questionnaire Step 1 of 5 20% Name: First NameMiddle Name Middle NameLast Name Last NameEmail Birth Date:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender: Male Female Your Occupation: Cell Phone:Worker's Comp. Insurance Company InformationName 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer InformationEmployer: Phone # of Employer:Type of Business:Accounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherEmployer's Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Injury InformationDate Injured: MM slash DD slash YYYY Time Injured: : AM PM AM/PM In your own words please describe work injury and how it happened:Last Date Worked: MM slash DD slash YYYY Are you currently working normal hours/duties? Yes No Did you report your injury to your employer? Yes No Name of the person your reported injury to: Address Where Your Were Injured: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Length of Time Worked There Prior to Your Injury: Type of work being done at time of injury:Prior to this injury have you ever had any of the physical complaints similar to what you have now? Yes No If yes, please provide details:Have you been treated by an other doctor(s) for this injury? Yes No Doctor's name(s): What type of treatment did you receive? Did the treatment help? Yes No Since your injury, are your symptoms? Getting worse Staying the same Getting better Are you taking medication related to your injury? Yes No If yes, what type(s) of medication are you taking? Are the medications helping? Yes No Did you miss any time from work? Yes No How long? Have you returned to work since this injury? Yes No If yes, when? MM slash DD slash YYYY If you have returned to work are you working: Have you had any other serious accidents which required medical care? Yes No Please describe: Have you had any other illness that required hospitalization? Yes No Please Describe: Current Medical ComplaintsBack Pain:Currently, I have pain in my: Lower Back Mid Back Upper Back My pain began: Gradually Suddenly I have pain in my back: All of the Time Most of the Time Sometimes My pain goes into my: Left Leg Right Leg Both Legs I have tingling and/or numbness in my: Left Leg Right Leg Both Legs My back pain is worse when I: Bend Cough or Sneeze Lift Pull Push Sit Walk My back is worse with sexual activity: Yes No My back pain wakes me up during the night: Yes No Changes in the weather affect my back pain: Yes No Neck Pain:My neck pain began: Gradually Suddenly I have neck pain: All of the Time Most of the Time Sometimes My pain goes into my: Left Arm Right Arm Both Arms I have tingling and/or numbness in: Left Arm Right Arm Both Arms My neck pain is worse when I: Bend Cough or Sneeze Lift Pull Push Sit Walk My neck pain wakes me up during the night: Yes No Changes in the weather affect my neck pain: Yes No I have neck stiffness: Yes No I have headaches: Yes No When I do get a headache, they occur: Constant Sometimes How often? Other Symptoms:Please check all that you are experiencing or have experienced since the injury: Anxiousness Arm Numbness/Tingling Arm Pain Depression Dizziness Fainting/Lightheadedness Fatigue Grating Noises in Neck Head Seems Heavy Headache(s) Irritability Lack of Energy Leg Numbness/Tingling Leg Pain Lower Back Pain Light Sensitivity Loss of Balance Loss of Memory Mid Back Pain Muscle Cramping Muscular Tension/Stiffness Neck Pain Neck Stiffness Pinched Nerve Ringing in Ears Shortness of Breath Shoulder Blade Pain Shoulder Pain Sleeping Problems Tight Chest Upper Back Pain Other None of the Above 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:BalancingNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the timeBend/StoopNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the timeClimbNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the timeCrawlNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the timeCrouchNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the timeKneelNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the timePushing/PullingNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the timeReach Above Shoulder LevelNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the timeSquatNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the timeOn the job, I lift:Up to 10 poundsNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the time11 to 24 poundsNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the time25 to 34 poundsNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the time35 to 50 poundsNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the time51 to 74 poundsNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the time75 to 100 poundsNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the time100+ poundsNever= 0% of the timeRarely= 1-5% of the timeOccasionally 5-33% of the timeFrequently=34-66% of the timeContinuously= 67-100% of the timeDo you have to bend over while doing any lifting? Yes No Additional CommentsPhoneThis field is for validation purposes and should be left unchanged.
