Workers’ Compensation Questionnaire (Online)

Complete this if your visit is related to a work injury. Prefer paper? Download the PDF.

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Patient & claim

Patient name

Date

WC insurance name

Date of accident

Attorney name

Attorney telephone

Attorney address

State

Zip code

Body part(s) injured while at work

Cause and circumstances of accident

Employment

Employer

Occupation

Employer address

State

Zip code

Employment status

Full time

Part time

As needed

Did you report your accident that day?

Yes

To whom

Did you complete your work duties that day?

Yes

How many days of work did you miss immediately after the injury?

Are you working now?

Yes

If no, last day of work

Prior care for this injury

When did you first seek medical care?

With whom / where

Physical therapy?

Yes

If yes, who?

Chiropractic treatment?

Yes

If yes, who?

Seen any other pain management doctors?

Yes

If yes, who?

What treatment have you had up to now?

Any chronic / pre-existing injuries contributing to current injury?

Signature

Patient signature (type full name)

Date

Cancel

Workers’ Compensation Questionnaire

New patient — work injury

Patient & claim

Employment

Prior care for this injury

Other occurrences

Signature

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