New York Workers Compensation New Patient History Form
Date
Name
Home Address
Home Phone #
Cellular Phone #
Alternate Phone #
Date Of Birth:
Social Security #
Age:
Date of Accident:
Weight:
Height:
Workers Compensation Board Case # (if known)
Carrier Case # (if known)
Gender
On the date of the accident what was your job title/description
Are you Right or Left handed?
On the day of the accident, what were your usual work activities?
Employer When Injury Occured:
Company / Agency Name
Phone #
Address
Who Referred you to our office?
How did you get to our office today?
Check all that apply.
Employer's Insurance Carrier:
Carrier Code #
W
Insurance Carrier's Address
E-Mail Address
Did you drive?
History
Describe briefly how the accident/injury occured:
Any history of prior accidents, injuries or surgery? Please provide details below, including dates.
What area(s) of your body was (were) injured?
Medical Care on the Day of the Accident / Injury
Did you go to a hospital?
If yes, which one?
Were you admitted?
If yes, for how long?
Treatment
Please list the names of all health care providers you have seen for this injury and indicate their specialty.
Describe any treatments received to date, (including physical therapy, acupuncture, chiropractic adjustments, surgery, etc.).
Indicate any tests and testing dates, you have taken or are scheduled to take
List medications you are taking
Allergies?
If yes, to what?
Work History
Are you currently working?
If yes,
Was time lost from work due to your injury?
If yes, provide dates:
If not working, what specifically do you feel prevents you from returning to work?
If you are not working, how do you spend your average day?
List all symptoms and complaints related to your injury
What activities of daily living are you able to perform?
Cooking
Cleaning
Grocery Shopping
Take care of children
Tending to personal hygiene
If necessary, provide details below, regarding activities of daily living
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REHABILITATION MEDICINE GROUP
Male
Female
Right
Left
Bus
Taxi
Train
Walk
Other:
Car
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Retired
Full duty
Light Duty
Part Time
yes
No
Yes
No
Yes
No
yes
No
Yes
No
Yes
No