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CASCADE HEALTH CAREPaul Rosasco, D.C. Makala Shelly, D.C.827 S. Burlington Blvd., Burlington, WA 98233 Phone (360) 757-4101 Fax (360) 757-4808WORKERS COMPENSATION HISTORYPatient Name _________________________________________________Date ___________________Address ___________________________City_________________ State ______ Zip Code __________(Home) Phone _________________ (Work) Phone________________ (Cell) Phone ________________Social Security #____________________________________Email Address: __________________________________Sex M F Marital Status M S D W Date of Birth__________________ Age___________Date of Injury: ______________________1. Name of employer at time of accident: __________________________________________________2. Length of time worked there prior to accident: ___________________________________________3. Type of work being done at time of injury: ___________________________________________________________________________________________________________________________________4. In your own words, please describe the accident: __________________________________________________________________________________________________________________________________________________________________________________________________________________5. Have you been treated by another doctor for this accident? ( )YES( ) NO If yes, please list doctor’s name and address: _______________________________________________ ____________________________________________________________________________________What type of treatment did you receive? ___________________________________________________How long were you treated by this doctor?6. Are you:( ) Improved( ) Unchanged( ) Getting Worse7. What type of medicines are you taking? _____________________________________________________________________________________________________________________________________8. Have you had physical therapy? ( ) NO( ) YESIf yes, how often? ( ) Daily( ) Every other day( ) Several times a week( ) Weekly( ) Every other week( ) Monthly( ) Other: _________________________________Does physical therapy help?( ) YES( ) NO( ) DON’T KNOW9. Prior to this accident, have you ever had any of the physical complaints similar to what you have now?( ) YES( ) NO( ) DON’T KNOWIf yes, describe: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Were these similar complaints the result of a previous accident(s)?( ) YES( ) NOPlease provide details of accident(s): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________10. Have you had any other serious accidents with required medical care?( ) YES( ) NODescribe: ___________________________________________________________________________11. Have you had any serious illness that required hospitalization?( ) YES( ) NODescribe: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________12. Have you had any surgeries?( ) YES( ) NOIf yes, list type of surgery and date: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________13. Have you ever had any nervous or mental illness?( ) YES( ) NOHave you had psychiatric care?( ) YES( ) NO14. Have you received a medical discharge from the Armed Forces?( ) YES( ) NO15. Have you returned to work since this accident?( ) YES( ) NOIf you have returned to work since your accident, please fill out the information below:DATEEMPLOYEROCCUPATIONLIGHT DUTYREG. DUTYFULL-TIMEPART-TIMECURRENT MEDICAL COMPLAINTSBACK PAIN:1. Currently, I have pain in my:( ) low back( ) mid back( ) Upper back2. My pain began:( ) gradually( ) suddenly3. I have pain:( ) sometimes( ) all of the time4. My pain goes into my:( ) right leg( ) left leg( ) both5. I have tingling/numbness in my:( ) right leg( ) left leg( ) both6. My pain is worse when I:Cough or sneeze( ) Yes( ) NoSit( ) Yes( ) NoBend( ) Yes( ) NoWalk( ) Yes( ) NoLift( ) Yes( ) NoPush( ) Yes( ) NoPull( ) Yes( ) NoBACK PAIN CONT.7. My back is worse with sexual activity( ) Yes( ) No8. My pain wakes me during the night ( ) Yes( ) No9. Changes in weather affect my pain ( ) Yes( ) NoNECK PAIN:1. My neck pain began:( ) gradually( ) suddenly2. I have pain:( ) sometimes( ) all of the time3. My pain goes into my:( ) right arm( ) left arm( ) both4. I have tingling/numbness in my:( ) right arm( ) left arm( ) both5. My pain is worse when I:Cough or sneeze( ) Yes( ) NoBend Forward( ) Yes( ) NoLift( ) Yes( ) NoPush( ) Yes( ) NoPull( ) Yes( ) NoTurn head( ) Yes( ) No6. My pain wakes me during the night ( ) Yes( ) No7. Changes in weather affect my pain ( ) Yes( ) No8. I have neck stiffness( ) Yes( ) No9. I have headaches( ) Yes( ) No10. If I do get headaches, they occur ( ) sometimes( ) all of the timeOTHER PAIN: Please describe any current medical complaints which you are experiencing and were not previously covered on this questionnaire, or list any additional comments you wish to make regarding your condition: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________JOB DESCRIPTION:(In terms of an 8-hour work day, “occasionally” means 33%, “frequently” means 34% to 66%, and “continuously” means 67% to 100% of the day)1. In a typical 8-hour work day, I: (Circle # of hours/ activity)Sit:12345678hoursStand: 12345678hoursWalk:12345678hours2. On the job, I perform the following activities:NOT AT ALLOCCASIONALLYFREQUENTLYCONTINUOUSLYBend/stoop( )( )( )( )Squat( )( )( )( )Crawl( )( )( )( )Climb( )( )( )( )Reach above ( )( )( )( )shoulder levelCrouch( )( )( )( )Kneel( )( )( )( )Balancing( )( )( )( )Pushing/ Pulling( )( )( )( )3. On the job, I lift:NOT AT ALLOCCASIONALLYFREQUENTLYCONTINUOUSLYUp to 10 pounds( )( )( )( )11 to 24 pounds( )( )( )( )25 to 34 pounds( )( )( )( )35 to 50 pounds( )( )( )( )30 to 74 pounds( )( )( )( )75 to 100 pounds( )( )( )( )4. Do you have to bend over while doing any lifting?( ) Yes( ) No5. Are your feet used for repetitive movements, such as operating foot controls? ( ) Yes( ) No6. Do you used your hands for repetitive actions, such as:SIMPLE GRASPINGFIRM GRASPINGFINE MANIPULATINGRight hand( ) Yes( ) No ( ) Yes( ) No( ) Yes( ) NoLeft hand( ) Yes( ) No( ) Yes( ) No( ) Yes( ) No7. Are you required to work on unprotected heights?( ) Yes( ) NoDescribe: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________8. Are you required to be around moving machinery? ( ) Yes( ) NoDescribe: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________9. Are you exposed to marked changes in temperature and humidity? ( ) Yes( ) NoDescribe: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________10. Are you required to drive automotive equipment? ( ) Yes( ) NoDescribe: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________11. Are you exposed to dust, fumes, and/or gases? ( ) Yes( ) NoDescribe: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________12. Please list any additional comments:___________________________________________________ ________________________________________________________________________________________________________________________________________________________________________Patient Signature: _________________________________________ Date: ______________________ ................
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