Workers Compensation Injury Questionnaire Step 1 of 5 20% Name:First NameMiddle NameLast NameEmail Birth Date:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender:MaleFemaleYour 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Injury InformationDate Injured: Time Injured: : HH MM AM PM In your own words please describe work injury and how it happened:Last Date Worked: Are you currently working normal hours/duties?YesNoDid you report your injury to your employer?YesNoName of the person your reported injury to:Address Where Your Were Injured: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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?YesNoIf yes, please provide details:Have you been treated by an other doctor(s) for this injury?YesNoDoctor's name(s):What type of treatment did you receive?Did the treatment help?YesNoSince your injury, are your symptoms?Getting worseStaying the sameGetting betterAre you taking medication related to your injury?YesNoIf yes, what type(s) of medication are you taking?Are the medications helping?YesNoDid you miss any time from work?YesNoHow long?Have you returned to work since this injury?YesNoIf yes, when? If you have returned to work are you working:Have you had any other serious accidents which required medical care?YesNoPlease describe:Have you had any other illness that required hospitalization?YesNoPlease Describe: Current Medical ComplaintsBack Pain:Currently, I have pain in my: Lower Back Mid Back Upper Back My pain began:GraduallySuddenlyI have pain in my back:All of the TimeMost of the TimeSometimesMy pain goes into my:Left LegRight LegBoth LegsI have tingling and/or numbness in my:Left LegRight LegBoth LegsMy back pain is worse when I: Bend Cough or Sneeze Lift Pull Push Sit Walk My back is worse with sexual activity:YesNoMy back pain wakes me up during the night:YesNoChanges in the weather affect my back pain:YesNoNeck Pain:My neck pain began:GraduallySuddenlyI have neck pain:All of the TimeMost of the TimeSometimesMy pain goes into my:Left ArmRight ArmBoth ArmsI have tingling and/or numbness in:Left ArmRight ArmBoth ArmsMy neck pain is worse when I: Bend Cough or Sneeze Lift Pull Push Sit Walk My neck pain wakes me up during the night:YesNoChanges in the weather affect my neck pain:YesNoI have neck stiffness:YesNoI have headaches:YesNoWhen I do get a headache, they occur:ConstantSometimesHow 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?YesNoAdditional CommentsPlease Enter the Above Code and Click "Submit" to Complete this Form. 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