Your Name (required)

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    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.