WORKERS’ COMPENSATION DATA SHEET

Date:_____________________________      Referred by:_________________________

Name:__________________________________________________________________

Date of Birth_______________________       Social Security Number:________________

Address:           Street or P.O. Box:____________________________________________

City:_______________________ State:______________ Zip Code:_________________

Telephone:(Home)_____________________(Work)_____________________________

Name and Address of Employer:_____________________________________________

_______________________________________________________________________

Job Title/Description:______________________________________________________

Earnings at Time of Injury:________________________________Per(hour,week,month)

Date of Accident:_______________Location:___________________________________

Witness to Accident:_______________________________________________________

Name & Title of person notified:___________________________Date______________

Brief Description of Accident:_______________________________________________

________________________________________________________________________

________________________________________________________________________

Describe part(s) of body injured or involved:____________________________________

________________________________________________________________________

Employer’s Insurance Carrier:_______________________________________________

                                    Adjuster:______________________________________________

                                    Telephone:_____________________________________________

Is Employer currently providing medical treatment?______________________________

Are you currently receiving Temporary Total Disability benefits?            Yes______No______

If so, how much?__________________________________________________________

Date of first payment:_____________________Last payment______________________

Have you reached maximum medical improvement?___________When?_____________

Please list all treatment facilities and/or physicians:______________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Do you have a private health insurance carrier?  Yes______      No_______

If yes, who?_____________________________________________________________

Are you covered by an independent disability policy from your employer?

Yes_____ No_____

If yes, who?_____________________________________________________________

Have you received any benefits from them? Yes________ No________

If yes what kind?_________________________________Amount_________________

Have you ever filed for workers’ compensation or been in an automobile accident prior to this date of 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