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Employee Injury Questionnaire

Gathers the full medical history of a worker hurt on the job: prior conditions, surgeries, restrictions, medications and past accidents. Each section is signed and dated for the personnel file.

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Page 1

Employee personal details

Employee signature*

Sign here

Date*

Employer name

Email*

Employee name*

Date of birth*

Sex*

Female Male Non-binary Prefer not to say

Social Security number (last 4 digits only)*

Home address*

Phone number*

Page 2

Medical history: answer for each condition

Diabetes

Yes No Not sure

Silicosis

Yes No Not sure

Varicose veins

Yes No Not sure

Asbestosis

Yes No Not sure

Hyperinsulinism

Yes No Not sure

Alzheimer's disease

Yes No Not sure

Emphysema

Yes No Not sure

Hearing loss

Yes No Not sure

COPD

Yes No Not sure

Hypertension

Yes No Not sure

Head injury

Yes No Not sure

Epilepsy

Yes No Not sure

Stroke

Yes No Not sure

Cerebral palsy

Yes No Not sure

Tuberculosis

Yes No Not sure

Multiple sclerosis

Yes No Not sure

Post-traumatic stress

Yes No Not sure

Osteomyelitis

Yes No Not sure

Nervous disorder

Yes No Not sure

Muscular dystrophy

Yes No Not sure

Migraine headaches

Yes No Not sure

Intellectual disability

Yes No Not sure

Kidney disorder

Yes No Not sure

Loss of use of a limb

Yes No Not sure

Seizure disorder

Yes No Not sure

Sickle cell disease

Yes No Not sure

Arthritis

Yes No Not sure

Parkinson's disease

Yes No Not sure

Brain damage

Yes No Not sure

Asthma

Yes No Not sure

Dementia

Yes No Not sure

Thrombophlebitis

Yes No Not sure

Arteriosclerosis

Yes No Not sure

Hodgkin's disease

Yes No Not sure

Cancer

Yes No Not sure

Double vision

Yes No Not sure

Mental disorders

Yes No Not sure

Hemophilia

Yes No Not sure

Bleeding disorder

Yes No Not sure

Heart disease / heart attack

Yes No Not sure

Congestive heart failure

Yes No Not sure

Vision loss, one or both eyes

Yes No Not sure

Disability from polio

Yes No Not sure

Psychoneurotic disability

Yes No Not sure

Ruptured or herniated disc

Yes No Not sure

Ankylosis or joint stiffening

Yes No Not sure

High or low blood pressure

Yes No Not sure

Carpal tunnel syndrome

Yes No Not sure

Compressed air sequelae

Yes No Not sure

Disease of the lung

Yes No Not sure

Coronary artery disease

Yes No Not sure

Heavy metal poisoning

Yes No Not sure

Previous surgeries and procedures

Spinal disc surgery*

Yes No Not sure

Spinal disc surgery year

Spinal fusion surgery*

Yes No Not sure

Spinal fusion surgery year

Amputated foot*

Yes No Not sure

Side

Left Right Both

Year

Amputated leg*

Yes No Not sure

Side

Left Right Both

Year

Amputated arm*

Yes No Not sure

Side

Left Right Both

Year

Amputated hand*

Yes No Not sure

Side

Left Right Both

Year

Knee replacement*

Yes No Not sure

Side

Left Right Both

Year

Hip replacement*

Yes No Not sure

Side

Left Right Both

Year

Other joint replacement*

Yes No Not sure

Joint

Year

Other surgical procedure 1*

Yes No Not sure

Procedure

Year

Other surgical procedure 2

Yes No Not sure

Procedure

Year

Other surgical procedure 3

Yes No Not sure

Procedure

Year

Other surgical procedure 4

Yes No Not sure

Procedure

Year

Employee signature*

Sign here

Date*

Page 3

Other diagnosed conditions

Condition

Brief explanation

Year diagnosed

Are you still being treated for this condition?

Yes No Not sure

Are you taking medication for this condition?

Yes No Not sure

Do you have any permanent restrictions for this condition?

Yes No Not sure

Condition

Brief explanation

Year diagnosed

Are you still being treated for this condition?

Yes No Not sure

Are you taking medication for this condition?

Yes No Not sure

Do you have any permanent restrictions for this condition?

Yes No Not sure

Condition

Brief explanation

Year diagnosed

Are you still being treated for this condition?

Yes No Not sure

Are you taking medication for this condition?

Yes No Not sure

Do you have any permanent restrictions for this condition?

Yes No Not sure

Condition

Brief explanation

Year diagnosed

Are you still being treated for this condition?

Yes No Not sure

Are you taking medication for this condition?

Yes No Not sure

Do you have any permanent restrictions for this condition?

Yes No Not sure

Employee signature*

Sign here

Date*

Page 4

Current restrictions and treatments

1. Has any doctor ever restricted your activities?*

Yes No Not sure

1A. If yes, please list the restrictions

1B. Were the restrictions...

Temporary Permanent Intermittent

1C. Are your activities currently restricted?

Yes No Not sure

1D. What is the medical condition for which you have restrictions?

2. Are you presently treating with a doctor, chiropractor, psychiatrist, psychologist or other healthcare provider?

Yes No Not sure

2A. Please list the medical condition being treated

2B. Doctor's name

2B. Doctor's address

2C. Doctor's specialty

Current medications

Medication

Prescribing doctor

Medication

Prescribing doctor

4. Have you ever had an on-the-job accident?*

Yes No Not sure

If you answered yes, please provide the date and nature of each injury

How long were you on compensation?

Name of employer

5. Has a doctor recommended a surgical procedure not yet completed, including but not limited to a knee, hip or shoulder replacement?*

Yes No Not sure

Recommended surgery details

Recommended surgery

Approximate date of recommendation

Doctor's name

Doctor's address

Doctor's specialty

Employee signature*

Sign here

Date*

Page 5

Employee declaration and signature

Employee signature*

Sign here

Date*

Employee printed name*

Page 6

For employer use only

Additional notes

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