Medical Treatment Worksheet

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2/9 EXAMPLES

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:
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:
Dates of treatment for each doctor/therapist
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: