PLEASE PRINT OUT THIS FORM AND SEND TO OUR OFFICES.
MEDICAL
DATA:
32. Nature of injuries __________________________________________________
____________________________________________________________________
Detailed
Injuries
33. I. Central Nervous System
Headaches___________________________________________________________
Memory
Loss_________________________________________________________
Personality Changes
Anxiety______________________________________________________________
Depression____________________________________________________________
Mood
swings__________________________________________________________
Loss of impulse control__________________________________________________
Irritability
sleep disorder_________________________________________________
Appetite changes_______________________________________________________
Eyes_________________________________________________________________
Ears-Ringing__________________________________________________________
PNS
Numbness
and tingling extremities_________________________________________
34. II. Chronic Fatigue, Fibromylagia, Chemical Sensitivity
Sensitive
to other chemicals, gasoline, smoking, solvents, pesticides, perfume
_____________________________________________________________________
_____________________________________________________________________
Fatigue,
tiredness and muscle fatigue________________________________________________________________
35. III. Respiratory
Upper
and Lower________________________________________________________
Shortness of breath, trouble breathing with or without
exposure
36. IV. IMMUNE/ AUTOIMMUNE
Fatigue, illnesses, flu____________________________________________________________________
37.
V. ENDOCRINE
Thyroid, adrenal, pituitary__________________________________________________
38. VI. LIVER
Blood
testing____________________________________________________________
Related mcs____________________________________________________________
39.
VII. GI
______________________________________________________________________
40. VIII. RASHES, ALLERGIES
______________________________________________________________________
41.
IX. CANCER
42. DO YOUR SYMPTOMS SEEM TO BE AGGRAVATED BY A SPECIFIC ACTIVITY?_____________________________________________________________
______________________________________________________________________
43. HAVE THERE BEEN ANY INCIDENCES OF
BIRTH DEFECTS SINCE THE EXPOSURE/OCCURRENCE? PLEASE EXPLAIN. _________________________
_____________________________________________________________________
44.
Names and addresses of current treating physicians:
1. ___________________________________________
2. ___________________________________________
3.
___________________________________________
45. Hospital care _____________________________________________
___________________________________________________________
46.
X rays _____________________________
47. Diagnostic testing___________________________________________________
_____________________________________________________________________
48.
Previous traumatic injuries:
1. __________________________________
2. __________________________________
3.
___________________________________
49. Previous NON traumatic injuries:
1. _____________________________
2.
_____________________________
3. ________________________________
50. Name and address of family physician _________________________________
______________________________
51. Date of last visit _________________
52. Reason for visit __________________
53.
Current medical program, if any ___________________________________
PERSONAL INTERESTS:
54.
Hobbies ______________________________________________________
55. Educational background _________________________________________
56.
Remarks ______________________________________________________
_________________________________________________________________
_________________________________________________________________
ATTACHMENTS:
1.
2.
3.
4.
5.
EMPLOYMENT HISTORY:
57. Name and address of present employer(or if disabled, last employer)
_____________________________
______________________________________________________
58. Job classification ____________________
59.
Length of employment _______________
60. Union ___________________
61. Base pay at date of accident hourly__________
weekly___________
62. Annually __________ Bonus and overtime ________________
63. Hours per week _______
64.
Commissions (if any ____________
65. Date stopped work _____________
66. Date returned to work __________
67.
PART TIME EMPLOYMENT (NAME AND ADDRESS). IF SELF EMPLOYED, PLEASE STATE
________________________________________________
_______________________________________________
68.
Earnings:
Weekly ___________ Monthly _____________ Annually ________________
69. Prior employment _____________________________________________
70.
Disability benefits______________________________________________