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Claimant Intake Form
IME INTAKE
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Last Name
First Name
WCB
Date of Birth
Gender
Male
Female
Are you:
Caucasian
African- American
Hispanic
Asian
Other
Height
Select Height
4 Feet 6 Inch
4 Feet 7 Inch
4 Feet 8 Inch
4 Feet 9 Inch
4 Feet 10 Inch
4 Feet 11 Inch
5 Feet 1 Inch
5 Feet 2 Inch
5 Feet 3 Inch
5 Feet 4 Inch
5 Feet 5 Inch
5 Feet 6 Inch
5 Feet 7 Inch
5 Feet 8 Inch
5 Feet 9 Inch
5 Feet 10 Inch
5 Feet 11 Inch
6 Feet 1 Inch
6 Feet 2 Inch
6 Feet 3 Inch
6 Feet 4 Inch
Weight
Eye Color
Select Eye Color
Black
Blue
Brown
Gray
Other
Hair
Select Hair Color
Black
White
Brown
Gray
Other
Are you:
Right- Handed
Left- Handed
How did you get to this office today?
Car
Bus
Taxi
Walk
Other
Did you drive
Yes
No
Type of Claim:
Motor Vehicle Accident
Workers Compensation
Other
If motor vehicle accident, were you:
Driver
Passenger
Seating Location
Pedestrian
Seat Belt:
Yes
No
Was vehicle hit from:
Front
Rear
Driver’s Side
Right side
Please explain in detail how your injury occurred:
Areas of Injury:
HEAD
NECK
MIDBACK
LOWER BACK
RIGHT SHOULDER
LEFT SHOULDER
RIGHT ELBOW
LEFT ELBOW
RIGHT WRIST
LEFT WRIST
RIGHT HIP
LEFT HIP
RIGHT KNEE
LEFT KNEE
RIGHT ANKLE
LEFT ANKLE
OTHER
Did you lose consciousness?
Yes
No
If yes, how much time were you not conscious?
Any lacerations (cuts):
Yes
No
If yes where?
Did you go to the emergency room?
Yes
No
If Yes, where?
Name of the Hospital/ER:
Were x-rays taken in the ER?
Yes
No
If yes, what body parts were x-rayed?
What other treatment did you receive in the ER?
Medication
Cane
Sling
Stitches
Neck Collar
Ace Bandage
Cast
Other
Were you admitted overnight to the hospital?
Yes
No
Name of the hospital:
Number of Days:
What type of treatment did you receive while in the hospital?
Medication
Physical Therapy
Chiropractic
Acupuncture
Other
What type of treatment are you receiving now : Please list below
Are you still receiving physical therapy?
Yes
No
If yes, times per week
Are you still receiving chiropractic treatment?
Yes
No
If yes, times per week
Are you still receiving acupuncture?
Yes
No
If yes, times per week
Did you receive medical supplies?
Yes
No
If yes, what type of supplies?
Due to the accident/ illness, what are your PRESENT SYMPTONS/ PAINS?
HEADACHE
NECK
MIDBACK
LOWER BACK
RIGHT SHOULDER
LEFT SHOULDER
RIGHT ELBOW
LEFT ELBOW
RIGHT WRIST
LEFT WRIST
RIGHT HIP
LEFT HIP
RIGHT KNEE
LEFT KNEE
RIGHT ANKLE
LEFT ANKLE
OTHER
PAST MEDICAL HISTORY:
Do you have any serious illness?
Hypertension
Diabetes
Asthma
Arthritis
OTHER
Any surgery due to this accident/case?
Yes
No
If yes, type of surgery & date:
Did you EVER have any other surgery?
Yes
No
If yes, type of surgery & date:
Do you take any medication(s) now?
Yes
No
If yes, please list:
Accupril
Aciphex
Actos
Adalat CC
Adderall
Advil
Aleve
Albuterol
Alesse-28
Allegra
Allegra-D
Allopurinol
Alphagan
Alprazolam
Altace
Amaryl
Ambien
Amitriptyline HCL
Amoxicillin Trihydrate
Amoxil
Amphetamine
Amyl nitrite
Anabolic Steroids
Aricept
Atenolol
Atenolol (Mylan)
Atrovent
Augmentin
Avandia
Avapro
Azmacort
Bactroban
Baycol
Biaxin
Buspar
Cardizem CD
Cardura
Carisoprodol
Ceftin
Cefzil
Celebrex
Celexa
Cephalexin
Cipro
Claritin
Claritin Reditabs
Claritin-D 12HR
Claritin-D 24HR
Climara
Clonazepam
Clonidine HCL
Colace
Combivent
Coumadin
Cozaar
Cyclobenzaprine
Depakote
Detrol
Diazepam
Diflucan
Dilantin
Diovan
Diovan HCT
Dulcolax
Effexor XR
Elocon
Ery-Tab
Evista
Flomax
Flonase
Flovent
Folic Acid
Fosamax
Furosemide
Gemfibrozil
Glucophage
Glucotrol XL
Glyburide
Hydrochlorothiazide
Hydrocodone
Hyzaar
Ibuprofen
Imitrex
Isosorbide Mononitrate
K-Dur
Ketamine
Klor-Con 10
Lanoxin
Lescol
Levaquin
Levothroid
Levoxyl
Lipitor
Lo Ovral
Loestrin FE
Lorazepam
Lotensin
Lotrel
Lotrisone
Lysergic Acid Diethylamide
Macrobid
Marijuana
MDMA
Medroxyprogesterone
Mescaline
Methamphetamine
Methylphenidate
Methylprednisolone
Metoprolol Tartrate
Miacalcin
Monopril
Morphine
Motrin
Naproxen
Naproxen Sodium
Nasonex
Neurontin
Nicotine
Norvasc
Ortho Cyclen
Ortho Tri-Cyclen
Oxycodone
OxyContin
Paxil
Penicillin VK
Pepcid
Phenergan
Plavix
Plendil
Potassium Chloride
Pravachol
Prednisone
Premarin
Prempro
Prevacid
Prilosec
Prinivil
Procardia XL
Promethazine
Propoxyphene
Proventil HFA
Prozac
Psilocybin
Ranitidine
Relafen
Remeron
Risperdal
Ritalin
Rohypnol
Roxicet
Serevent
Serzone
Singulair
Synthroid
Tamoxifen Citrate
Temazepam
Tiazac
Tobradex
Toprol-XL
Trazodone
Triamterene
Trimox
Triphasil
Tylenol
Ultram
Valtrex
Vasotec
Veetids
Verapamil
Viagra
Vicoprofen
Vioxx
Warfarin Sodium
Wellbutrin SR
Xalatan
Xenical
Zantac
Zestoretic
Zestril
Ziac
Zithromax
Zithromax Z-PAK
Zocor
Zoloft
Zyprexa
Zyrtec
Have you ever had a similar condition or prior accident?
Yes
No
If yes, describe, including date & Injuries:
EMPLOYMENT HISTORY:
At the time of the accident, did you have a job?
Yes
No
Retired
SSI Disability
If yes, what type or work?
Fulltime
Part-time
Did you miss time from work?
Yes
No
If yes, how much time?
Date returned
Are you actively working now?
Yes
No
If yes, same job (same duties)
Same job (limited duties)
Do you have a new job?
Yes
No
If yes, what type
CURRENT ACTIVITIES AND COMPLAINTS:
If you are NOT working What activities are you capable of performing?
Tending to personal hygiene
Cooking
Washing Dishes
Sweeping
Vacuum Cleaning
Taking care of children
Shopping for groceries
Baby Sitting
Volunteering
How long can you
Sit
Stand
Walk
Lie Down
How do you spend your average day?
Approximately how soon after the injury did you start treatments?
Are you better now than when you started treatments?
Yes
No
How many (minutes or hours or days) does relief last after treatments?
Your pain today is what? Using a scale of 1-10 (10 = worst):
Did you take pain medication today?
Yes
No
If yes, which medications
If yes, did it help with the pain?
Yes
No
A LITTLE
How would you describe the pain?
DULL
ACHY
BURNING
PULLING
NAGGING
TINGLING
SHARP
STABBING
OTHER
Does the pain radiate anywhere? If so, where?
Do you have difficulty with stairs?
Yes
No
How long can you sit before you are in too much pain?
What makes your pain worse?
Reaching overhead
Bending
Walking
Sleeping
Other
Do you experience any of the following:
LOCKING
CLICKING
BUCKLING
WEAKNESS
NUMBNESS
TINGLING
Alcohol Use:
Never
Occasionally
Moderate
Daily
Tobacco Use:
Never
Quit
When quit
Current pack/day
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Back
Bob Nilson
20:15
When could you send me the report ?
Ella Wong
20:15
Its almost done. I will be sending it shortly
Bob Nilson
20:15
Alright. Thanks! :)
Ella Wong
20:16
You are most welcome. Sorry for the delay.
Bob Nilson
20:17
No probs. Just take your time :)
Ella Wong
20:40
Alright. I just emailed it to you.
Bob Nilson
20:17
Great! Thanks. Will check it right away.
Ella Wong
20:40
Please let me know if you have any comment.
Bob Nilson
20:17
Sure. I will check and buzz you if anything needs to be corrected.
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