PERSONAL INJURY DATA SHEET (SLIP&FALL)

Date:_______________________                  Referred by:_________________________

Name:________________________________________SS#:______________________

Date of birth:_____________________

Spouse:_______________________________________SS#:______________________

Street/P.O.Box:___________________________________________________________

City:___________________________State:___________Zip Code:_________________

Telephone(Home):______________________ (Work):___________________________

Employer:___________________________________Supervisor:___________________

Job Title:____________________________________Rate of pay:__________________

Address:________________________________________Phone:___________________

Were you in the scope of your employment when the accident occurred?_____________

Private or group Insurance:_________________________________________________

            Have you filed medical bills on health insurance: Yes_______ No_______

DATE OF ACCIDENT:___________________________________________________

Location:_______________________________________________________________

City:_______________________________________State________________________

If this accident happened in a store or other business, please give the name of the manager and/or employee to whom you reported the accident:______________________

Please list names, addresses and phone numbers of any witnesses to the accident:________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Please give a brief description of the accident:___________________________________

_______________________________________________________________________

_______________________________________________________________________

Have you been contacted by an insurance company? Yes________ No________

Name of Company:________________________________________________________

Address:________________________________________________________________

Name of Adjuster:_________________________________________________________

Claim Number:___________________________________________________________

Please list all treatment facilities and/or physicians seen by you:

________________________________        ___________________________________
________________________________        ___________________________________
________________________________        ___________________________________
________________________________        ___________________________________
________________________________        ___________________________________

If you were treated at Keesler Medical Center or at any other military medical facility, please give us the following information:

If you are active/retired military, indicate your branch of service:____________________

If you are a military dependant, indicate the name and social security number of your sponsor, and his/her branch of service:_________________________________________________________________

Have you submitted any medical bills for payment by CHAMPUS or CHAMP/VA?

            Yes______ No_______

Have you submitted any medical bills for payment by MEDICAID or MEDICARE?

            Yes______ No_______

If yes, what state?____________________________

Are you receiving Social Security benefits? Yes___________ No___________

If yes, what type?_________________________________________________________

Have you ever been involved in any prior automobile accidents or workers’ compensation claims where you suffered an injury? Yes_______No_______

If yes please describe:______________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

PAIN CHART

Please describe your pain by this diagram.

Patient Name: ___________________________________ Date: _____________

PAIN DRAWING Use the symbols below to mark the areas on your body where you feel the following sensations. Include ALL affected areas.

BURNING    NUMBNESS    PINS & NEEDLES    STABBING    ACHES    OTHER

 XXXXXXX    OOOOOOO    ===============    ////////////////////    ^^^^^^    UUUUU

pain line

No pain ||Worst possible pain

The patient with a complaint of back pain fill out a pain drawing using this