State Workers' Compensation Appointment Protocol Builder

Client & Attorney Information

Date

Client / Patient Name

Address / PO Box

City

State

ZIP

Phone

Social Security Number

Date of Birth

Sex

Male Female

Referring Attorney

Attorney Phone

Attorney Address

Attorney Fax

Sensitive information stays in the browser while you build the PDF. Avoid using a public/shared computer.

Date of Injury

Type of Injury

Briefly describe what caused this injury

Where do you still have problems?

Briefly list pertinent treatment such as emergency care, imaging, physicians, medications, surgery, and physical therapy.

Treatment

Did you miss work due to this injury?

If yes, dates or estimated time missed

Other significant past or recent injuries

Pertinent past medical history

Pertinent family medical history

Medication allergies

Work Status

Education

Years in college or degrees

The body diagram on page 2 remains available on the finished PDF for the patient to circle pain/problem areas by hand.