DC
Dr. Chen Dermatology Intake
Workers' compensation questionnaire
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Patient
Contact and identifiers
Last name
First name
Today's date
Date of birth
Age
Sex
Male
Female
Height
Weight
Street address
City
Zip
Home phone
Cell phone
Emergency contact
Emergency phone
Claim
Claim basics
Date of injury or claim filed date
Other open claims
Yes
No
Other claim details
Attorney retained
Yes
No
When attorney was retained
Medical, Family & Social History
Background history
Current medications
Medication or environmental allergies
Yes
No
Allergy list
Personal medical history
If checked, diagnosis dates and treatments
Prior surgeries and dates
Family medical history
Family members and conditions
Smoke
Yes
No
Packs per week
Since
Alcohol
Yes
No
Alcohol amount per week
Marital status
Single
Married
Divorced
Separated
Widowed
Children
Yes
No
Number of children
Highest education completed
Year graduated
Country of origin if not born in U.S.
How long in the U.S.
Military service
Yes
No
Branch
Date discharged
Type of discharge
Is your claim for skin cancer?
Complete this section only if yes
Is your claim for skin cancer?
Yes
No
What is your main complaint? (skin cancer, spots on skin, etc.)
When did you first start to notice the above symptoms?
Did you seek any medical treatment on your own prior to filing your claim?
Yes
No
If yes, please specify
Have you ever been treated for actinic keratoses?
Yes
No
Not sure
Have you ever been treated with Efudex/Carac/Aldara cream?
Yes
No
Not sure
Do you have a history of skin cancer?
Yes
No
Not sure
If yes, please specify the location on the body and the date/year you had surgery
Basal cell
Basal cell - location on body and date/year of surgery
Squamous cell
Squamous cell - location on body and date/year of surgery
Melanoma
Melanoma - location on body and date/year of surgery
Please list your dermatologist/surgeon's name(s)
If you are currently seeing a dermatologist, when was your last appointment?
Do any of your family members have skin cancer?
Yes
No
Please specify
In a typical work day, how many hours do you spend working outdoors in the sun light?
At work, do you wear:
Hat with brim
Ball cap
Short sleeved shirt
Long sleeved shirt
Shorts
Trousers
Other
Other clothing worn at work
At work, what parts of your body are routinely exposed to sunlight?
Face
Neck
Arms
Chest
Back
Legs
Other
Other body parts exposed to sunlight
Do you use sunscreen at work?
Yes
No
Outside of work?
Yes
No
Did you have major sunburns as a child?
Yes
No
Have you used tanning booths in the past?
Yes
No
What is your ethnicity?
Did you participate in any youth sports activities from grade school to high school?
Yes
No
Please list
Do you have any hobbies that you like to do on a regular basis?
Yes
No
Please list
Is your claim for skin allergies or dermatitis?
Complete this section only if yes
Is your claim for skin allergies, dermatitis, or rash?
Yes
No
What is your main complaint?
When did you first start to notice the above symptoms?
Was there a specific incident at work that lead to your symptoms?
Did you see a doctor?
Yes
No
On your own or with the company doctor?
If yes, please list the name of your doctor and what type(s) of treatment you received
If you have not seen a doctor, have you tried using treatments including over-the-counter medications on your own?
Are you currently under treatment with a doctor for your skin rash?
If yes, what types of treatment or medications are you currently using?
When did you report your injury?
Whom did you notify?
Do you have any history of eczema, asthma, hay fever, seasonal allergies, hives?
Eczema
Asthma
Hay fever
Seasonal allergies
Hives
Any of your family members have history of eczema, asthma, hay fever, seasonal allergies, hives?
Yes
No
Please specify
Do you have history of any food or environmental allergies?
Yes
No
Please specify
Have you had patch testing or any allergies testings?
Yes
No
Please specify
Have you had a skin biopsy?
Yes
No
Please specify
What makes your symptoms better?
What makes your symptoms worse?
Do you handle any types of chemicals, cleaning agents adhesives, metals, foods at work?
Are you exposed to any dust or fumes at work?
Yes
No
Please specify
Do you wear gloves at work?
Yes
No
If yes, what type?
Are you aware of other co-workers who have the same condition?
Yes
No
Do you notice an improvement of your symptoms when you are away from work?
Yes
No
Is your claim for another skin injury?
Use this if it is not skin cancer or skin rash
Is your claim for anything other than skin cancer or skin rash?
Yes
No
Please describe how your injury occurred
Were there any witnesses?
Yes
No
Name
What happened immediately after the incident?
Did you go to a hospital/clinic?
Yes
No
Treatment received
If you did not seek or receive medical treatment immediately following the incident, when and for what reason, did you first seek or receive medical care?
List your doctor and the type(s) of treatment you received
Frequency and duration of the treatment
Are you currently still receiving any treatment for your injury?
Yes
No
What are your current complaints?
What makes your symptoms better?
What makes your symptoms worse?
Occupational History
Work status and duties
Employer at time of injury
Began working there
Job title
Work hours from
Work hours to
Schedule type
Full
Part
Job duties
Restrictions when hired
Yes
No
Restrictions when hired details
Presently working for same company
Yes
No
Left employer date
Reason
Concurrent jobs
Yes
No
Concurrent job details
New employer start date
Current employer
Current job title
Current job duties
Current restrictions
Time off due to skin injury
Yes
No
How long off work
Modified duty return date
Full duty return date
Expected return if on medical leave
If not working, seeking new job
How long off work
Return to work ability
Full duty
Modified duty
Not at all
Explanation
How skin injury affects day-to-day activities
Past employment
Add past job
Activities of Daily Living
Last month
ADL notes
Employee's Disability Questionnaire
DWC-AD Form 100 (DEU), page 2
When is your examination scheduled?
What were your job duties at the time of your injury?
What is the disability resulting from your injury?
How does this injury affect you in your work?
Have you ever had a disability as a result of another injury or illness?
Yes
No
If so, when?
Please describe the disability?
Date
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