NEW CLIENT — SIBTF

Patient Name

Email Address

Date of Birth

Address

SSN

Phone

Working currently?

Gender

Height

Weight

Interpreter's Name

Today's Date

Have you had or do you have any of the following respiratory conditions?

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any respiratory conditions that were not listed above? If so, name them and list the date of onset for each condition.

Have you had or do you have any of the following psychological conditions?

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any psychological conditions that were not listed above? If so, name them and list the date of onset for each condition.

Have you had or do you have any of the following skin conditions?

Pruritus - itching and scratching
Scars
Skin grafts
Allergy to latex gloves
Skin cancer
Burns
Dermatitis - hives
Discoloration/pigment changes
Psoriasis - eczema

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any skin conditions that were not listed above? If so, name them and list the date of onset for each condition.

Have you had or do you have any of the following blood conditions?

Anemia
Spleen disease
Blood transfusion
Bleeding easily
Bruising easily
Leukemia
Red/white blood cell disorder

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any blood conditions that were not listed above? If so, name them and list the date of onset for each condition.

Have you had or do you have any of the following endocrine (glandular) conditions?

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any endocrine (glandular) conditions that were not listed above? If so, name them and list the date of onset for each condition.

Have you had or do you have any of the following gastrointestinal (digestive) conditions?

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any gastrointestinal (digestive) conditions that were not listed above? If so, name them and list the date of onset for each condition.

Have you had or do you have any of the following urinary system conditions?

Excessive urination
Unexpected urination
Difficulty urinating
Prostate disease
Kidney disease/kidney stones
Bladder disease - infections
Blood in the urine

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any urinary system conditions that were not listed above? If so, name them and list the date of onset for each condition.

Have you had or do you have any of the following Ear - Nose - Throat - Mouth conditions?

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any Ear - Nose - Throat - Mouth conditions that were not listed above? If so, name them and list the date of onset for each condition.

Have you had or do you have any of the following sexual dysfunction conditions?

Sexual dysfunction
Erectile dysfunction

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any sexual dysfunction conditions that were not listed above? If so, name them and list the date of onset for each condition.

Have you had or do you have any of the following cardiovascular (heart) conditions?

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any cardiovascular (heart) conditions that were not listed above? If so, name them and list the date of onset for each condition.

Have you had or do you have any of the following vision conditions?

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any vision conditions that were not listed above? If so, name them and list the date of onset for each condition.

Have you had or do you have any of the following arthritis conditions?

Osteoarthritis
Rheumatoid
Lupus
Gout
Psoriasis

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any arthritis conditions that were not listed above? If so, name them and list the date of onset for each condition.

Have you had or do you have any of the following fractures?

Upper extremity
Lower extremity
Torso - ribs - chest
Pelvis
Spine
Cranium - skull - face

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any fractures that were not listed above? If so, name them and list the date of onset for each condition.

Have you had or do you have any of the following types of headaches?

Migraine
Cluster
Cervical - muscle tension
Post traumatic
Menopausal
Sinus
Stress
Rebound from taking medicine

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any types of headaches that were not listed above? If so, name them and list the date of onset for each condition.

Have you had or do you have any of the following conditions?

If you selected any choices for the above question, please list the date of onset of each one of your conditions.

Do you have any other conditions that were not listed in any of the above lists? If so, name them and list the date of onset for each condition.

List below the doctors, facilities, hospitals, and clinics that treated and evaluated you with city and address.

Information About Your Last Work Injury

Employer Name

Date of Work Injury

Are you still working with this employer?

Yes
No

If no, what was the last day you worked at this employment?

Please describe the body parts that were injured as a result of this work injury.

Please list the permanent disability rating as a result of this work injury, if known.

Information About Health Before Your Last Work Injury

Did you have any conditions, difficulties, or health problems before the work injury?

Yes
No

If yes, please list all your prior conditions, illnesses, limitations, difficulties or health concerns below

Any prior problems with your upper or lower extremities or eyes?

Yes
No

If yes, select your prior conditions from the list below.

If you selected any conditions above, please identify the date of onset for each condition below.

Current Home Care

Which of the following do you do for home care?

Please describe current home care below.

Current Aids

Which of the following aids do you use?

If you selected "Other," list your other aid(s)?

Please describe all aids currently being used and how frequently they are used.

Current Medications

What type of medications do you currently use?

If you take any other medications, please list them here.

Source of medication

Over-the-counter
Prescription
Both

Please list all of the medications you're currently taking and how often you take them.

Surgical History

Please list all surgeries you've had and the date they were performed.

SIBTF

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Information About Your Last Work Injury

Information About Health Before Your Last Work Injury

Current Home Care

Current Aids

Current Medications

Surgical History