Patient info | Work Capacities, LLC

The following is a health form for you to complete. Please complete and PRINT and bring with you for your appointment. Changes will not be saved.

WORK CAPACITIES, LLC

541-306-6175

Name:

Claim no:

Date of injury:

Phone number:

_________________

Your height:

Your weight:

Name and title of employer representative we can contact regarding your claim:

Have you seen a physician regarding this condition?

Yes. Treating physician: _________________________ Phone: ___________________________

Address: ____________________________________________________________________

Date follow-up appointment: ____________ Physician’s name: _______________________

No. If not, do you plan to see a physician? Please provide the physician’s name and the

date of your appointment: ____________________________________________________

Description of your problem/injury: What part of your body was injured? (Please list all parts you feel were injured.) __________________________________________________________________

___________________________________________________________________________________

Please list the specific job duties you feel led to this condition: _______________________________

___________________________________________________________________________________

How long have you been doing this particular job? _________________________________________

In the past, have you done this or a similar job with a different employer? Yes. No. If yes, please provide name(s) of employer or company: ________________________________________

___________________________________________________________________________________

Have you been injured or been treated for any condition of this part(s) of your body before?

Yes. No. If yes, please describe the condition and the treatment received, and provide the name of your physician. ______________________________________________________________

___________________________________________________________________________________

If you have injured this part of your body before, what types of treatment did you receive? (Including surgery, traction, physical therapy, acupuncture, herbal/ naturopathy, chiropractic, etc.) ___________________________________________________________________________________

Please provide approximate dates of treatment and names of treating physicians. ______________

___________________________________________________________________________________

Have you been involved in any motor vehicle accidents resulting in injury? Yes. No. If yes, please list date(s) of accident(s). _______________________________________________________

___________________________________________________________________________________

Are you active in any sports or recreational activities or hobbies? Yes. No. If yes, please list.

___________________________________________________________________________________

Do you have any other jobs or self-employment activities not listed above? Yes. No. If yes, please list. _________________________________________________________________________

___________________________________________________________________________________

YES

Diabetes

Thyroid or other endocrine/glandular problems (adrenal, lymph glands, menopause, etc.)

Problems with your circulatory system (heart disease, hardening of the arteries, high blood pressure, Raynaud’s disease, etc.)

Problems with your nervous system (including brain, nerves, depression, etc.)

Water retention problems

Are you currently or have you recently been pregnant?

Have you experienced recent changes in your weight?

Have you ever been hospitalized or had surgery performed or advised?

Have you had any recent abnormal diagnostic studies (lab, xrays, ultrasound, etc.)?

Have you sought professional advice or been treated because of the use of alcohol or drugs any time in the past five years?

Do you have impairment by conditions not mentioned above?

Prior to your injury, were you taking medication? If yes, please list. ________

___________________________________________________________________

YES	NO
		m.	Veterans’ benefits? Claim no: __________________________________________
		n.	Adult and Family Services benefits? Type and ID no: _______________________
		o.	Social Security benefits? Type: _________________________________________
		p.	Workers’ Compensation benefits? List states, company names, and claim numbers:___________________________________________________________ ___________________________________________________________________
		q.	Any other benefits? (e.g., disability, wage subsidy, unemployment, Oregon Health Plan)? Type and ID numbers: __________________________________________ ___________________________________________________________________
		r.	Have you ever gone by another name? If yes, list all names and dates used. __ ___________________________________________________________________ ___________________________________________________________________

This information is complete and accurate to the best of my knowledge.


Your Signature		Date

Please list all physicians you have treated with in the past five years:

1.	Name:
	Address:
	Telephone no:
	Condition treated:
2.	Name:
	Address:
	Telephone no:
	Condition treated:
3.	Name:
	Address:
	Telephone no:
	Condition treated:
4.	Name:
	Address:
	Telephone no:
	Condition treated:
5.	Name:
	Address:
	Telephone no:
	Condition treated:
6.	Name:
	Address:
	Telephone no:
	Condition treated:


Your Signature		Date