Worker's Compensation Health History Questionnaire

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Worker's Compensation Health History Questionnaire

History Present Illness
Your Past Medical/Surgical History - Please circle all that apply:
Previous Injuries to Affected Body Areas:

Similar Problems in the Past:

Anxiety Disorder

Chronic Pain

Emphysema

High Blood Pressue

Seizure

Asthma

Congestive Heart Failure

Head injury

High Cholesterol

Stroke

Bleeding Problem

Depression

Heart attack?

Kidney Disease

Thyroid Disease

Carpal Tunnel

Diabetes?

Hepatitis B or C

Liver Disease

TIA

Cancer

Social History

Do you smoke or chew tobacco

Do you consume alcohol

Review of Systems: Please check all that apply:
Constitutional
Musculoskeletal
Genitourinary
Cardiovascular
ENT
Skin and Breast
Respiratory
Gastrointestinal
Neurological
Endocrine
Eyes

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