Your Name (required)Phone (required) D.O.B (required)WORK:DRUGS/ALCOHOLAre you currently working? YESNOLast time used illicit drugs? (required) When did you stop working? (required) Last time drank alcohol? (required) Any unsuccessful attempts to go back to work? YESNOLIMITATIONS / ACCOMMODATIONS / DISABILITIESHow long are you able to: Sit: Minutes Hours Stand: Minutes Hours Do you use any of the following (city blocks): How much can you lift (pounds):Do you need to elevate your legs: YesNoDo you use any of the following (check all that apply):CANEWALKERBRACE Are any of the above prescribed by an MD?YESNOACTIVITIES OF DAILY LIVINGCheck any of the following you need help with: Getting out of bedHairBathing/showeringCleaningNails/shavingLaundryMeal prep/cookingGetting dressedSURGERIES/OVERNIGHT HOSPITAL STAYSList any surgeries and the reason for each surgery:List any overnight hospital stays and the reason for the hospitalization:PLEASE MAKE SURE THAT INFORMATION BELOW COVERSTREATING PHYSICIANS/CLINICS/ HOSPITALSName of the PhysicianDate of VisitedStreet AddressFisrt VisitCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipLast SeenPhone Next AppointmentCLAIM NUMBER (if any)REASONS FOR VISITS:TREATING PHYSICIANS/CLINICS/ HOSPITALSName of the PhysicianDate of VisitedStreet AddressFisrt VisitCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipLast SeenPhone Next AppointmentCLAIM NUMBER (if any)REASONS FOR VISITS:TREATING PHYSICIANS/CLINICS/ HOSPITALSName of the PhysicianDate of VisitedStreet AddressFisrt VisitCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipLast SeenPhone Next AppointmentCLAIM NUMBER (if any)REASONS FOR VISITS:TREATING PHYSICIANS/CLINICS/ HOSPITALSName of the PhysicianDate of VisitedStreet AddressFisrt VisitCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipLast SeenPhone Next AppointmentCLAIM NUMBER (if any)REASONS FOR VISITS:PLEASE LIST BELOW THE PRESCRIPTION MEDICATION WHICH YOU ARE PRESENTLY TAKING. IF THE NAME OF THE MEDICATION IS NOT SHOWN ON THE PRESCRIPTION CONTAINER, YOU MAY VERIFY THE NAME WITH YOUR PHARMACIST.NAME OF MEDICATION & DOSAGEDATE FIRST PRESCRIBEDDAILY AMOUNT TAKENREASON FOR MEDICATIONNAME OF PHYSICIANNAME OF MEDICATION & DOSAGEDATE FIRST PRESCRIBEDDAILY AMOUNT TAKENREASON FOR MEDICATIONNAME OF PHYSICIANNAME OF MEDICATION & DOSAGEDATE FIRST PRESCRIBEDDAILY AMOUNT TAKENREASON FOR MEDICATIONNAME OF PHYSICIANNAME OF MEDICATION & DOSAGEDATE FIRST PRESCRIBEDDAILY AMOUNT TAKENREASON FOR MEDICATIONNAME OF PHYSICIANNAME OF MEDICATION & DOSAGEDATE FIRST PRESCRIBEDDAILY AMOUNT TAKENREASON FOR MEDICATIONNAME OF PHYSICIANNAME OF MEDICATION & DOSAGEDATE FIRST PRESCRIBEDDAILY AMOUNT TAKENREASON FOR MEDICATIONNAME OF PHYSICIANNAME OF MEDICATION & DOSAGEDATE FIRST PRESCRIBEDDAILY AMOUNT TAKENREASON FOR MEDICATIONNAME OF PHYSICIANNAME OF MEDICATION & DOSAGEDATE FIRST PRESCRIBEDDAILY AMOUNT TAKENREASON FOR MEDICATIONNAME OF PHYSICIANNAME OF MEDICATION & DOSAGEDATE FIRST PRESCRIBEDDAILY AMOUNT TAKENREASON FOR MEDICATIONNAME OF PHYSICIANNAME OF MEDICATION & DOSAGEDATE FIRST PRESCRIBEDDAILY AMOUNT TAKENREASON FOR MEDICATIONNAME OF PHYSICIAN PLEASE LIST BELOW THE NONPRESCRIPTION MEDICATION YOU ARE TAKING AND THE REASONS YOU TAKE THEM. Submit