Workers Compensation Claim Print this form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.* indicates a required fieldExaminee Information FormPlease complete this form to the best of your ability. All fields are required on this form – if a field does not apply to you, please input N/A.First Name *Middle Initial *Last Name *Date of birth *Age *Sex at Birth *MaleFemalePreferred PronounsDominant Hand *Right-handedLeft-handedAddress Line 1 *Address Line 2City *State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code *Home Phone *Attending Physician *What is your ethnic group? *CaucasianAfrican-AmericanAsianHispanicNative-AmericanOther (please specify below)Other (Ethnic Group) *Your Employer and Job Title at time of injury *Length of time worked for that employer at time of injury *Are you currently employed? *YesNoAre you working? *YesNoIf so, are you under any restrictions from your doctor? *Health Status InformationWhen did your problem begin? *Which one of the following best describes the way your medical problem began? *Accident at workExposure at workMotor Vehicle AccidentFollowing an illness or medical treatmentBegan spontaneouslyAccident some place elseOther (specify below)Other *Please describe your job in detail *Please tell us how your medical problem began (how it happened, date and place of injury) *Please describe your current symptoms *Medical HistoryInjuries – Please list all major injuries you have had and their approximate dates. *Illnesses – Please list all major illnesses you have had or have now. *Surgeries – Please list all major surgeries you have had and their approximate dates. *Hospitalizations – Please list all of the times you have been hospitalized and their approximate dates, except for surgeries. *Please list all of the things, including medications, food, pollens, dust, etc., that you are allergic to. *Please list all of the medications you are taking right now, including dosage and when taken. *Family HistoryDo any medical problems run in your family? *YesNoIf yes, please explain *Socioeconomic HistoryMarital Status *SingleMarriedNever MarriedDivorcedWidowedLiving with significant otherNumber of dependent children *Highest education level attained *Grade level completed (specify below)Completed junior highSome high schoolCompleted high school/GEDCompleted some college (specify below)Completed Voc/Tech programCompleted some graduate school (specify below)College graduate (4 year degree)Specify grade level or years *Were you ever in the military? *YesNoIf yes, what branch? *Years of service *Type of discharge *Any service-related disability? *Are you currently employed? *YesNoAre you receiving time-loss compensation? *YesNoFull or part time? *Full timePart timeIs this the same job you had at the time of injury? *YesNoIf you have a different job now, who is your present employer? *Personal HabitsDo you smoke, vape or use other tobacco products? *YesNoIf yes, please explain how many products/vapes/packs per day. *Do you drink alcohol? *YesNoIf yes, what type and how much per week? *Do you use recreational drugs? *YesNoIf yes, what kind? *Please list hobbies/activities prior to injury *Please list any changes in hobbies/activities since the injury *MessageSubmit
