Injuried Worker Questionnaire

1.                    What is your full name?                                     

 

 

2.                    What is your date of birth?                                               

 

 

3.                    Are you?          Right Handed                   Left Handed                  Either

 

 

4.                    What is the date of your injury?

 

 

5.                 Have you ever had any previous problems or injuries, including any other work-related, recreational, or motor vehicle injuries?                                              Yes      No       Not sure

 

              If yes, please describe:

 

 

6.             Have you ever had any difficulties prior to the date of your injury that were similar to those you are now experiencing?                                                            Yes     No      Not sure

 

If yes, please describe:

 

 

7.             Please describe how your injury occurred:

 

 

 

8.             What problems did you have at that time?

 


 

9.                    What did you do following the injury?

 

 

 

10.                 Briefly describe what has occurred since that time to this date:

 

 

 

11.                 What is your greatest concern at this time?

 

 

 

If you are not having difficulty with pain, proceed to question 18.

 

12.                 Where is your pain located?

 

 

 

13.                 How would you describe your pain?

 

 

 

14.                 What makes your pain worse?

 

 

 

15.                 What makes your pain better?

 

 

 

16.                 How frequent is your pain?       constant             (present : to all of the time

                                                                        frequent             (present 2 to : of the time)

                                                                        occasional         (present 3 to 2 of the time)

                                                                        intermittent        (present less than 3 of the time)

 

17.                 On a scale from 0 (no pain) to 10 (excruciating pain):

1.                    What number would you put on your pain at this time?       ______

2.                    During the past month, what has it averaged?                       ______

3.                    During the past month, what is the highest it has been?      ______

4.                    During the past month, what is the lowest it has been?       ______

 

18.    Are you having any others                                                                                                                                         

Yes:                No:                  No sure

If yes, please describe these difficulties in detail:

  

 

19.                Are any tasks difficult for you to perform?          Yes            No           Not sure  

If yes, please describe the tasks that are most difficult for you:

 

 

 

 

If your injury is not work-related, please proceed to question 28.

 

20.                 Who were you employed by when you were injured?

 

 

 

21.                 How long had you been working there?

 

 

 

22.                 What was your job?

 

 

 

23.                 What did this job involve?

 

 

 

24.                 What type of work have you performed previously?

 

 

 

25.                 What is your level of education?

 

 

 

26.             Are you working now?             Yes         No          Not sure

             Please describe:

27.             Has your doctor, or anyone, prescribed any work restrictions?       Yes          No           Not sure        

 

              If yes, please describe these restrictions:

 

 

28.                 Where do you live?

 

 

 

29.                 Who lives with you?

 

 

 

30.                 Please describe your typical day:

 

 

 

31.                 Are you involved in any work activities or any significant recreational pursuits?     Yes      No        Not sure

 

If yes, please describe:

 

 

 

32.                 Do you smoke?       No       Yes, in the past, but I quit               Yes, ______ packs per day

  

33.                 How many alcoholic beverages do you have per week?     _______________

 

34.                 Have you had any medical hospitalization?             Yes         No       Not sure

If yes, please describe:

  

35.                 Have you had any complications?         Yes            No           Not sure

If yes, please describe:

 

 

 

36.               Are you taking any prescriptions?           Yes        No         Not sure  

               If yes, please list:

 

 

37.                Are you allergic to any medications?       Yes         No         Not sure      

If yes, please describe:

 

 

 

38.           Have you had any other medical problems?                                              Yes         No       Not sure

If yes, please describe:       

 

 

 

39.                 Do any diseases run in your family?    Yes      No       Not sure

If yes, please describe:

 

 

 40.                 Please provide any other comments that may assist us in understanding your situation: