Form Wch-209 Worker'S Compensation History Form

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Bakke Chiropractic Clinic
Worker’s Compensation History Form
Name:_______________________________________
Date_______________________ Case#________________
Approx. time of injury:______________  am
 pm
Date of injury:________________________________
Your occupation: ___________________________________________________________________________________
Explain how the injury happened (be specific)___________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Describe the environmental conditions which may have contributed to your injury (darkness, faulty equipment, slippery
floor, limited space, etc):_____________________________________________________________________________
__________________________________________________________________________________________________
Did you seek any treatment prior to today as a result of the injury?  Yes  No
Please explain:______________________________________________________________________________________
Were you taken off work or given any work restriction as a result of the injury?  Yes
 No
Are you currently on any work restriction?  Yes  No Please explain: _____________________________________
__________________________________________________________________________________________________
Prior to this incident have you ever been injured /or had symptoms in the area now affected?  Yes
 No
If yes, please explain (be specific)______________________________________________________________________
Are your daily activities different since this injury?  Yes
 No Please explain: ___________________________
________________________________________________________________________________________________________________________
 Yes
 No
Have you contacted an Attorney?
EMPLOYER COMPENSATION INFORMATION
Employer’s Name:___________________________________________________________________________________
Employer’s Address:_________________________________________________________________________________
Person to Contact: ________________________________________________ Phone #: __________________________
Patient’s Social Security Number:____________________________________
Did you report the injury: Yes  No If yes, reported to?:________________________ Phone#: _____________
Did you fill out a work injury report and turn it in? Yes  No
**************************************************************************************************
For Office Use Only
Employer called: __________________
Has injury been filed?  Yes  No
Work comp carrier?
Carrier Address:
Phone#:
Claim # (assigned):
Date of injury:
My signature below verifies that I have read, understood and truthfully answered each question to the best of my ability.
Patient’s Signature:______________________________________________________ Date:____________________
Form# WCH-209 Rev 02/21/11

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