Head Trauma Case History Form (Page 3 of 4) in pdf

8. Difficulties Following Accident

A. Work Related

Please describe: _____________________________________________________________________________________

__________________________________________________________________________________________________

B. Hobbies/Avocational

Please describe: _____________________________________________________________________________________

__________________________________________________________________________________________________

C. Recreational/Social

Please describe: _____________________________________________________________________________________

__________________________________________________________________________________________________

D. Other

Please describe: _____________________________________________________________________________________

__________________________________________________________________________________________________

9. Other Information

Please take the time to share with us anything else that you feel is relevant:

__________________________________________________________________________________________________

I authorize the release of medical and/or other information pertinent to my care to the insurance company

in order for me to be reimbursed.

Signature: ____________________________________________ Date: ________________________

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Head Trauma Case History Form Page 3