Freedom Wellness Centers, LLC
Workers' Compensation History Form
Please describe the incident/injury in your own words: *

Where did the incident occur? *

Please include city, state and zip code.
Did anyone witness your injury?

If yes, then who witnessed your injury?

Did you report your injury to anyone?

If yes, who did you report your injury to?

Was the injury report written or verbal?

Have you retained an attorney?

If yes, please include your attorney's name, address and phone number:

Immediately following the accident, which of the following best describes your state?

If you lost consciousness, then how long were you unconscious?

Did you go to the hospital?

If yes, when?

If you went to the hospital, then how did you get to the hospital?

If you were transported via ambulance, did the ambulance attendants place you in any of the following:

If you were admitted into the hospital, please answer the following:

Name of the hospital?

Name of the doctor?

What was the diagnosis?

What treatment did you receive?

Did you have any x-rays taken at the hospital?

Did you have any other imaging taken at the hospital? (MRI/CT)?

Were there any other medical supplies or medications given? If yes, what?

Have you had any similar problems before?

If yes, please explain:

Have you lost any days of work from this injury?

If you have lost any days of work, then please list date(s):

Quadruple Visual Analog Scale (QVAS):

Please rate pain on a scale of zero to ten, with ten being the worst, presently:

Please rate pain, at its best, over the past 24 hours:

Please rate pain, on average, over the past 24 hours:

Please rate pain, at its worst, over the past 24 hours:
Please type your name:

Today's date

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