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Workers Compensation Injury Questionnaire

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Name:
First Name
Middle Name
Last Name
Email
Birth Date:
Gender:
- Male
- Female
Your Occupation:
Cell Phone:
Worker's Comp. Insurance Company Information
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

Injury Information
Date Injured:
Date Format: MM slash DD slash YYYY
Time Injured:

: HH

MM
In your own words please describe work injury and how it happened:
Last Date Worked:
Date Format: 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 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?
Date Format: 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 Complaints
Back 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:
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

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