Your Name (required)

Phone (required)

D.O.B (required)

WORK:
DRUGS/ALCOHOL

Are you currently working?
YESNO

Last time used illicit drugs? (required)

When did you stop working? (required)

Last time drank alcohol? (required)

Any unsuccessful attempts to go back to work? YESNO

LIMITATIONS / ACCOMMODATIONS / DISABILITIES

How 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: YesNo

Do you use any of the following (check all that apply):CANEWALKERBRACE

Are any of the above prescribed by an MD?

YESNO

ACTIVITIES OF DAILY LIVING

Check any of the following you need help with:
Getting out of bedHairBathing/showeringCleaningNails/shavingLaundryMeal prep/cookingGetting dressed

SURGERIES/OVERNIGHT HOSPITAL STAYS

List 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 COVERS
TREATING PHYSICIANS/CLINICS/ HOSPITALS

Name of the Physician

Date of Visited

Street Address

Fisrt Visit

City

State

Zip

Last Seen

Phone

Next Appointment

CLAIM NUMBER (if any)

REASONS FOR VISITS:

TREATING PHYSICIANS/CLINICS/ HOSPITALS

Name of the Physician

Date of Visited

Street Address

Fisrt Visit

City

State

Zip

Last Seen

Phone

Next Appointment

CLAIM NUMBER (if any)

REASONS FOR VISITS:

TREATING PHYSICIANS/CLINICS/ HOSPITALS

Name of the Physician

Date of Visited

Street Address

Fisrt Visit

City

State

Zip

Last Seen

Phone

Next Appointment

CLAIM NUMBER (if any)

REASONS FOR VISITS:

TREATING PHYSICIANS/CLINICS/ HOSPITALS

Name of the Physician

Date of Visited

Street Address

Fisrt Visit

City

State

Zip

Last Seen

Phone

Next Appointment

CLAIM 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 & DOSAGE

DATE FIRST PRESCRIBED

DAILY AMOUNT TAKEN

REASON FOR MEDICATION

NAME OF PHYSICIAN

NAME OF MEDICATION & DOSAGE

DATE FIRST PRESCRIBED

DAILY AMOUNT TAKEN

REASON FOR MEDICATION

NAME OF PHYSICIAN

NAME OF MEDICATION & DOSAGE

DATE FIRST PRESCRIBED

DAILY AMOUNT TAKEN

REASON FOR MEDICATION

NAME OF PHYSICIAN

NAME OF MEDICATION & DOSAGE

DATE FIRST PRESCRIBED

DAILY AMOUNT TAKEN

REASON FOR MEDICATION

NAME OF PHYSICIAN

NAME OF MEDICATION & DOSAGE

DATE FIRST PRESCRIBED

DAILY AMOUNT TAKEN

REASON FOR MEDICATION

NAME OF PHYSICIAN

NAME OF MEDICATION & DOSAGE

DATE FIRST PRESCRIBED

DAILY AMOUNT TAKEN

REASON FOR MEDICATION

NAME OF PHYSICIAN

NAME OF MEDICATION & DOSAGE

DATE FIRST PRESCRIBED

DAILY AMOUNT TAKEN

REASON FOR MEDICATION

NAME OF PHYSICIAN

NAME OF MEDICATION & DOSAGE

DATE FIRST PRESCRIBED

DAILY AMOUNT TAKEN

REASON FOR MEDICATION

NAME OF PHYSICIAN

NAME OF MEDICATION & DOSAGE

DATE FIRST PRESCRIBED

DAILY AMOUNT TAKEN

REASON FOR MEDICATION

NAME OF PHYSICIAN

NAME OF MEDICATION & DOSAGE

DATE FIRST PRESCRIBED

DAILY AMOUNT TAKEN

REASON FOR MEDICATION

NAME OF PHYSICIAN

PLEASE LIST BELOW THE NONPRESCRIPTION MEDICATION YOU ARE TAKING AND THE REASONS YOU TAKE THEM.