workers compensation forms：工人补偿形式

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1、WORKERS’COMPENSATIONHISTORYPLEASEFILLINTHEFORMASCOMPLETELYASPOSSIBLE.NOTIFYOURSTAFFIFYOUHAVEANYQUESTIONS;THEYWILLBEGLADTOHELPYOU.Patient’sName:_______________________________________Date:_____________Address:_____________________________________City:_____________________

2、State:______Zip:___________HomePhone:_____________WorkPhone:_________SocialSecurity#:___________________DriverLic#__________________________DateofBirth:___________________Age:___________Sex:FMRight/LeftHandedHeight:________Weight:_________Smoker:______Married:YNNearestRe

3、lative:____________________________Phone:______________________INJURYINFORMATIONDateofInjury:_________________Timeofinjury:_____________________Employerattimeofinjury:________________________________________________Dateofhire:__________________Lengthoftimeworked:________

4、_____________DateClaimFiled:______________LastDateofEmployment:__________________Pleaselistallbodypartsinjured:_______________________________________________________________________________________________________________________________________Priortothedate(s)abovehav

5、eyoueverinjuredthesamearea(s)ofyourbody?_______Didyouhaveapre-employmentphysicalexamination?YesNoAnyworkrestrictionsbasedonthatexam?YesNoExplain:______________________Describehowtheinjuryhappened:(Didyoufall,wereyoustruckbysomething,wereyouinanautoaccident,wereyouusingsp

6、ecialequipment,etc…)Describewhatpartofyourbodywasinjuredintheaccident:______________________Whatkindofpainordiscomfortdidyouexperienceatthetimeofinjury?_____________________________________________________________________________________Page2Didyoureporttheaccidentatthet

7、imeofinjury?YesNoIfsotowhom?__________________________________________________________Werethereanywitnessestotheaccident,ifso,who?______________________PASTMEDICALTREATMENTWhatoccurredimmediatelyaftertheaccident?(Wereyouprovidedwithmedicaltreatment,etc...)_______________

8、_________________________________________Didyougotoahospital?YesNoClinic?YesNoWhen?_________________Ify