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Medical Treatment for Personal Injury Worksheet Example
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Text in this example:
Hospital Name and address of ambulance company: Name and address of emergency room: Mode of transportation to the emergency room: Treatment at emergency room: Medication: Orthopedic appliances: Arrival time: am/pm Departure time: am/pm Mode of transportation home: Condition for the rest of the day/night: Ability to sleep: Condition the next morning: Medical Treatment Worksheet Injury Injuries as a result of the accident: Type of pain (sharp or dull, constant or intermittent): Continued Treatment Name,address, phone number, and speciality of your family doctor: Name,address, phone number, and speciality of all doctors/therapists seen for your injuries: Mode of transportation: Purpose of visits: Referral source for each doctor: Results of first doctor visit: Results of subsequent visit: Description of treatments/therapy: Exercises: Whirlpool: Orthopedic appliances: Dates of treatment for each doctor/therapist Medication: Date of last medical treatment: Continuing Effects Pain when discharged: Medical instructions upon discharge: Pain since discharge: Pain today: Surgery: Effect on household duties: Effect on exercise/sports: Effect on driving: Effect on sleeping: Effect on social activities: Marital difficulties: Emotional reaction to your injuries: Your physical/emotional condition before the accident: Prior/subsequent accidents: Prior/subsequent injuries: Prior/subsequent doctors: Effect on Work Next scheduled day of work after the accident: Time missed because of the accident: Reason for missing time: Effect of accident on ability to work after return to your job: Work schedule: Average weekly wage: Name, phone, number, and address of supervisor: