Author: Christina

Dr. William Previte
WORKERS COMP PATIENT QUESTIONAIRE
DATE OF APPOINTMENT: ________________________________
NAME: ___________________________________________________________________________
ADDRESS: _______________________________________________________________________
(Please include city & zip code)
TELEPHONE: HOME (____) ____________________ CELL: (____) _______________________
DATE OF BIRTH: ____________________ AGE: _____ SSN #: ____________________________
MARITAL STATUS: ______________ # OF CHILDREN: ___________ AGES: ________________
YOUR ATTORNEY’S NAME (If applicable) : ___________________________________________
INTERPRETER’S NAME / AGENCY (If applicable) : _____________________________________
INITIAL HISTORY OF INJURY:
Did your injury occur at work? _________________________________________________________
What part(s) of your body were injured? _________________________________________________
What was the date(s) of injury? _________________________________________________________
Who was your employer at the time? ____________________________________________________
What was your occupation there? _______________________________________________________
How long had you been working there at this time? _________________________________________
How did the injury/accident happen? ____________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Did you finish working? _____ Did you report the injury? ___________________________________
When? _________ To Whom? _________________________________________________________
Did you fill out a form? _______________________________________________________________

WORK HISTORY
Have you returned to work since the injury? __________________________________________________________
Give date _____________ Same employer? _________________________________________________________
If different employer, give name: __________________________________________________________________
Same job? ______________ Full duty or restricted duty? _______________________________________________
If restricted duty, list restrictions: __________________________________________________________________
_____________________________________________________________________________________________
Are you currently working? _______________________________________________________________________
If no, give last date of work: ______________________________________________________________________
Why did you stop working? _______________________________________________________________________
HISTORY OF INITIAL TREATMENT
When did you first see a doctor? ___________________________________________________________________
Name of doctor: ________________________________________________________________________________
Address: _________________________________________ City: ________________________________________
Who referred you to this doctor? ___________________________________________________________________
What tests were done? (Check appropriate tests below)
X-Ray_____ CT Scan_____ NCV/EMG_____ Myelogram_____ Arthogram_____ MRI_____
Other_______________________________________________________________________________
To what part of the body? _____________________________________________
What treatment was suggested? (Check any appropriate)
Rest_____ Meds_____ Physical Therapy_____ How often? _______________________________
Hospitalized?_____________________________ Dates: _______________________________________________
List below any other doctors that you have seen for this injury. Starting with the one you sdaw after the doctor above and ending with the most recent doctor you have seen.
Name________________________________________________ Date Seen: __________________________
Who referred you to this doctor? ___________________________________________________________________
2. Name________________________________________________ Date Seen: __________________________
Who referred you to this doctor? ___________________________________________________________________
3. Name________________________________________________ Date Seen: __________________________
Who referred you to this doctor? ___________________________________________________________________

DESCRIPTION OF JOB DUTIES
List your regular duties for the employer at the time you were injured: __________________________________________
__________________________________________________________________________________________________
Check those that apply: Number of Pounds Required: % of day spent on this duty:
Lifting to chest level ________________ ________________
Lifting above shoulder level ________________ ________________
Pushing/Pulling ________________ ________________
Carrying ________________ ________________
Bending ________________
Squatting ________________
Kneeling ________________
Standing ________________
Sitting ________________
Driving ________________
Climbing ________________
Repetitive Hand Movements ________________
PRESENT COMPLAINTS
Do you have pains? _______ Where is it? ________________________________________________________________
What does it feel like? (Sharp, dull, aching, stabbing, etc.) ___________________________________________________
Did any of these symptoms exist prior to your injury/illness? _________________________________________________
Does your present pain travel to any other parts of the body? _____________ Where? _____________________________
How often does it occur? _________________________ What makes it worse? _________________________________
What makes it better? ________________________________________________________________________________
Is there any stiffness? _________ Where? ________________________________________________________________
Is there any numbness? ________ Where? ________________________________________________________________
Is there any tingling? ________ Where? __________________________________________________________________
Is there any weakness? ________ Where? ________________________________________________________________
Any swelling in joints? ________ Where? ________________________________________________________________
Any grinding in joints? _________ Where? _______________________________________________________________
Any locking in joints? _________ Where? ________________________________________________________________
Any giving way of joints? ________ Where? ______________________________________________________________

Are there any bowel or bladder problems? _________________________________________________________
Deformity/Scar? _______________ Where? ________________________________________________________
Are you right or left handed? ___________________________________
PAIN DIAGRAM
Using these pictures, indicate which parts of your body are affected by pain. Please use the
symbols below:
N N N Dull /// /// /// Stabbing / cutting
X X X Burning ::::::::: Tingling (pain & needles)
= = = Numb SSS Cramping

Pain Rating Scale
Also, please circle which applies best:

PAST INJURIES
*Use reverse of this page to list any additional injuries*
Previous injuries, NOT RELATED TO YOUR WORK INJURY:
Date: _____________ What body part was involved: __________________________________________________
Treatment type? ___________________________________________________________________________________
How long? _______________________________ Symptoms resolved? _______________________________________

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