Insurance Company:

Address:

Do Not Use This Space
Claim No.
Policy No.
Class Code.

1. Employee’s First Name: Middle Initial: Last Name:

2. Social Security No.:

3. DOB:

4. Sex:

5. Street Address: City: State: Zip:

6. Phone No.:

7. Ht.:

8. Wt.:

9. Name of Employer:

10. Address:

11. Phone No.:

12 Date Injured: Hour:

AM PM

13. Last Date Worked:

14a. Has This Part Been Injured Before?
yes
no

14b. If “Yes” State When and Describe:

15. Employee’s Statement of Cause of Injury or Illness (In First Person):

16. Describe Complaints (In First Person):

17. Findings of Examination:

18. X-Rays? Yes No

Findings:

19. ICD-9 Codes:

20. Diagnosis (Written Description)

21. Is the Condition Requiring Treatment the Result of the Industrial Injury or Exposure Described?

Yes No Undetermined If “No” Explain:

22. Date of First Treatment: Hour

AM PM

23. Type of Treatment:

24. If Hospitalized, What Hospital?

In-Patient Out-Patient

25. If case Referred to Another Physician, Give Physician’s Name and Address

26. Is Condition Medically Stationary?

Yes No

27. Is Any Further Treatment Required?
Yes No
If “Yes” Date of Next Visit and How Many Estimated?

28. Will Injury Cause Permanent Impairment? Yes No

29. Does Injury Prevent Return to Regular Employment? Modified Employment?
Yes No          If “Yes” Estimate Time Loss: Yes No

If “Yes” Explain Restrictions:

30. Date Released for Work:

31. Remarks or Outline of Proposed Treatment:

32. Are There Any Conditions That Would Retard or Prevent Recovery? Yes No

33. Name of Physician and Degree:

34. Address:

35. Phone No.:

36. Federal Tax I.D. Number

37. Date:

38. Signature (Physicians Own Signature Please):

White: Industrial Commission

Yellow: Employee

Pink: Insurance Carrier

Goldenrod: Physicians’ File