Use Patient Plate
Workman’s Compensation Questionnaire All information in this questionnaire will be included in your medical record and will be held strictly confidential.					Today’s Date
Primary Physician Name & Address
Referring Physician Name & Address (if different from primary care physician)
Name: (Last, First, M.I.)						M F	Date of Birth
							Age
History of Present Illness
What part of your body is driving you to seek medical attention? HIP KNEE OTHER
Which side?	If you have an injury to the affected part, when did it occur?
How did the injury or accident happen?
What makes your pain better? (rest, ice, heat, massage, medications)
What makes your pain worse? (activity, walking, running, bending, squatting)
What is the quality of your pain (sharp, dull ache, burning, other)
How many hours a day do you have this pain?
Do you have pain at rest?				Yes No
Does the pain radiate to anywhere else? If yes, where?
Do you have any of the following?
swelling Yes No				popping or clicking Yes No
numbness Yes No				giving way Yes No
What limitations of your daily routine do you have due to this injury?
Have you injured this area prior to this injury? If so, explain.
Occupational Information
What is your job title?
Did your injury occur at work?				Yes No
Was it due to a single injury or due to a gradual problem?				Single injury Gradual
Who was your employer at the time of the injury?
Please describe how the injury occurred.
Have you reinjured yourself since that time?				Yes No
How would you described the function of the injured body part BEFORE the injury?				Excellent Very Good Good Fair Poor(Constant Pain)
Name of the First doctor that you saw after the injury?				Date?
How did you get there? Driven Ambulance Other
What initial tests did you have? Xrays CT MRI EMG Bone Scan
What treatment was initially performed?
Were you taken off work? Yes No
Were you given modified duty? Yes No
Were you hospitalized? Yes No
Did you have physical therapy? Yes No

List other medical specialists that you have seen since the initial visit after your work related injury. Start with the first one after the initial evaluation and end with the most recent visit.
Name	Date seen		Tests (EMG, CT, MRI, Bone scan)	Treatment		Hospitalized? If yes, dates?	Surgery? If yes, what procedure?
Work Status Since Time of Injury?
On what approximate date did you return to work?
How many days of lost work did you have?
What date did you work last?
Do you have a new employer since your injury? Yes No
What are your usual duties?
What are current work duties can you not perform as a result of your injury?
How long have you been working with your present employer?
Do you have to lift?
If so how much?
Do you have to kneel, bend, or squat? Yes No
If so how often?
Please list your previous employers in chronological order (most recent first)
Employer		Occupations			Dates

Do you use any walking aids		Yes No
If so, what do you use?	Cane Walker Crutches Wheelchair
What percent of the time do you use walking aids?		%
Do you use any braces?		Yes No
Do you use any orthotics in your shoes? If yes, please explain:		Yes No Explain
How far can you walk?		Miles Yards Blocks
What treatments have you had for your current condition?
Cortisone injections? If yes, when and how often?		Yes No Explain
Viscosupplementation? (Synvisc, Hyalgan) If yes, when and how often?		Yes No Explain
Do you take any antiinflammatory medications?		Yes No
Do you take Chondroitin Sulfate and Glucosamine?		Yes No
Do you have difficulty with stairs?		Yes No
Do you have more difficulty going up or down stairs?		Up Down
Do you put both feet on each step?		Yes No
Do you use a rail when going up and down steps?		Yes No
Can you put on your shoes and socks?		Yes No
Can you cut your toenails yourself?		Yes No
Please list any known medical conditions or problems.			Year of onset
Please list surgeries that you have undergone.			Year performed

Injuries, Car Accidents, or Broken Bones:
Year	Incident	Treatment	Status	Work Related?
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No

Please list any over the counter or prescribed medications.
Drug Name	Strength or Dose	Taken when and how often?
Medication Allergies: No Known Allergies OR			1.
			2.
			3.

FAMILY HISTORY: Please list any illnesses of family members or cause of death if known.
	Age	Mark X if Alive and Well	Mark X if deceased	Describe family member illness or cause of death if known
Mother
Father
Sisters
Brothers
Children

Review of Systems: Check if you have had, or currently have any of the following symptoms and the date of onset
	Symptom	Date of Onset	Symptom	Date of Onset
	Fevers		Phlebitis
	Chills		AIDS
	Night Sweats		Hepatitis B
	Rashes/Frequent Itching		Hepatitis C
	Sores that don’t heal		Previous Deep Vein Thrombosis
	Hearing Loss		Transient Ischemic Attacks (TIA’s)
	Nasal Problems		Seizures
	Difficulty Swallowing		Calf Pain on Exertion
	Thyroid Problems		Easy Bruisability
	Weight Loss		Swollen Nodes
	Weight Gain		Paralysis
	Excessive sweating		Weakness
	Tremor		Numbness
	Chest Pain		Tingling in Arms or Legs
	Shortness of Breath		Painful Urination
	Cough		Frequent Urination
	Enlarged Heart		Bloody Urine
	Irregular Heart Beat		Bleeding Ulcers
	Heart Murmur		Hiatal Hernia
	Wheezing		Frequent Indigestion
	Vein Problems		Colitis
	Others:

Social and Activity History: This information may impact your health insurance. If you have any concerns about this please leave the information blank and discuss it verbally with your physician to ensure confidentiality.

Smoking (Tobacco)

How many per day?

How many years?

Cigarettes

Yes No

Cigars

Yes No

Pipe

Yes No

Alcohol

Yes No

Illicit Drugs

Are you currently using or have you used any illicit drugs such as methamphetamine or cocaine? Yes No

Have you ever used intravenously injected drugs such as heroin? Yes No

Highest Grade of School Completed

Elementary HighSchool College Post-Graduate

Current Occupation

Marital Status

Single Married Divorced Widowed Other

Hobbies/Activities/Sports

How many hours a week do you perform these activities?

Physical Examination (To be filled out by MD)

General

Standing Alignment Varus Valgus Deg

App

Gait Trend Antalgic Side

Hip

Knee

TTP

Yes No Location

Effusion

Standing Alignment

ROM (Extension)

TTP

Flexion

Extension

ABD

Medial

Lateral

ADD

ER

IR

Stability

ROM (90 Flexion)

Varus

Valgus

Flexion

Extension

ABD

Lachman

Post Drawer

ADD

ER

IR

Patellofemoral Joint

Anterior Apprehension

Posterior Apprehension

Crepitance

Apprehension

LLD

Eql

R>L

L>R

cm?

Flexion

Extension

Vascular DP PT

Sensory

DTR

KJR R L

AJR R L

Motor Q JS TA GS EHL FHL