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Workman's Compensation History Form
Workman’s Compensation HISTORY
Last Name
*
First Name
*
Date
*
Insurance Company
Claim Number
Adjuster’s Name
Insurance Phone #
Name of Attorney
*
Attorney Phone Number
*
Date of Accident
*
Time
12
1
2
3
4
5
6
7
8
9
10
11
:
00
15
30
45
AM
PM
Please describe the accident and be as specific as possible
*
4. At the time of the accident, recall were parts of your body hit or injured? What parts?
*
Head/ Body position at the time of impact:
*
Head turned left/right
Body straight in sitting position
Head looking back
Body rotated right/left
Head straight forward
Other
Other
As a result of the accident you were:
*
Rendered unconscious
In shock
Dazed, Circumstances Vague
Other
Other
Were you wearing a hat or glasses?
*
Yes
No
Could you move all parts of your body?
*
Yes
No
What parts couldn’t you move and why?
*
Were you able to get out of the car and walk unaided?
*
Yes
No
Why not?
*
Did you get any bleeding cuts?
*
Yes
No
Where?
*
Did you get any bruises?
*
Yes
No
Where?
*
Please describe how you felt:
Immediately after the accident:
*
Later that day:
*
The next day:
*
Check ALL symptoms that you have notice since the accident:
*
Headache
Neck Pain/ Stiffness
Mid Back Pain
Eyes Light Sensitive
Pain Behind Eyes
Dizziness
Fainting
Sleeping Problems
Numbness in Fingers
Numbness in Toes
Loss of Smell
Loss of Taste
Loss of Memory
Fatigue
Breath Shortness
Irritability
Depression
Ringing/ Buzzing
Loss of Balance
Tension
Cold Hands
Cold Feet
Diarrhea
Constipation
Chest Pain
Nervousness
Cold Sweats
Anxious Driving
Facial Pain
Clicking or Popping Jaw
Low Back Pain
Other
Other
If you are human, leave this field blank.
Submit
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