NEW CLIENT INFORMATION

FULL NAME:
ADDRESS:
HOME PHONE:		WORK PHONE:
CELL PHONE:		E-MAIL:
SOCIAL SECURITY NUMBER
AGE:		DATE OF BIRTH:
PRIMARY LANGUAGE:		SECONDARY:
COUNTRY:		DIALECT:

OTHER CONTACT INFORMATION:

NAME:		PHONE:
NAME:		PHONE:
WHO REFERRED YOU TO OUR OFFICE?

EMPLOYMENT INFOMRATION AT TIME OF INJURY

EMPLOYER NAME
EMPLOYER ADDRESS
EMPLOYER PHONE
DATE OF INJURY:		COUNTY OF INJURY:
Position:
Length of Time Employed:

Earnings

Hourly $

Hours per week

**********PLEASE PROVIDE A COPY OF MOST RECENT PAY STUB**********

Briefly describe the physical demands of your job (example: lifting, bending, prolonged standing, kneeling, squatting, etc.)


If terminated, state reason why

Do you know who your employer's workers' compensation insurance company is for the date of your injury? (If you have received or are receiving a weekly workers' compensation checks, the issuer of the check is the workers' compensation insurance company.)

Are you currently receiving workers' compensation benefits? If yes, how much?

Are you receiving medical bills from your doctor(s) demanding payment?

* At the time of your injury, were you working ANOTHER full-time or part-time job?

ACCIDENT INFORMATION

HOW WERE YOU HURT?(Please describe in detail)

WHO DID YOU NOTIFY OF YOUR INJURY?

Name	Title/Position	Date/Time Notified

WERE THERE ANY WITNESSES TO YOUR ACCIDENT?
(If so, please list below)

Name	Address	Phone

Are you currently out of work because of your injury?
If so, what was the first date you missed work?
After your injury, did you stop working?
How much time did you miss from work?
Have you returned to work?
If so, what was the date you returned to work?

MEDICAL TREATMENT RECEIVED

Please list all doctors, hospitals, phsyical therapists, etc. you have seen since your work-related injury.

Name	Address	Phone

Did any doctor tell you to stay out of work?
If so, who?
PART(S) OF BODY INJURED
Have you ever injured these body part(s) before? (If so, please describe when, how, and if it was work-related.)


Who provided medical treatment for this previous injury to these body part(s)?


If this previous injury was work-related, please list your previous employer

Was a workers' compensation claim filed?

If so, what was the outcome?

PRIOR WORK HISTORY

Employer Name/Address - Position - Dates Employed - Salary - Reason Left
1.
2.
3.
Have you ever filed a workers' compensation claim before?
If so, please list below:
Employer Name/Address - Type of Injury - Date - Outcome
1.
2.

Prior Medical History

Family Doctor (Please list Name, Address, Phone)

When was the last time you saw any doctor?

For what reason?

Have you ever been hospitalized?
Dates - Reason - Doctor

MISCELLANEOUS

1. Do you have any outstanding Child Support Liens?

2. Do you have any other personal injury actions pending as a result of this accident?

3. Ever been charged with a felony?