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
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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