This document contains a work/compensation questionnaire for a patient named seeking treatment from Dr. R. Mark Pappas, including details about their accident, symptoms, job duties, and current medical complaints related to pain in their neck, back, arms and legs. The questionnaire collects information about the accident, treatment received, symptoms experienced, job activities like sitting, lifting and reaching, and any other medical conditions.

1. Dr. R. Mark Pappas
299 Main Street
West Haven, CT 06516
203-937-7246
Work/Comp Questionnaire
Name: ________________________________ DOB/Age: ___________ _____
Sex:
M
F
Address: _______________________________________________________________________
Name of Employer at time of accident: ______________________________________________
Employers address: ______________________________________________________________
Your occupation: ______________ Position: _____________Time Employed There:_________
Dates out of work: ____________________
Date returned to work: _________________
Please Describe the accident:
_______________________________________________________________________________
_______________________________________________________________________________
Have you filed an accident report at work?
Yes ____
No ____
Have you been treated by another doctor for this injury? _______ If yes, please list
doctor’s name and address:
_______________________________________________________________________________
Are you? :
improving: ____
unchanged: ____
What type of treatment did you receive: Medication _____
getting worse: ____
Therapy _____ X-Rays _____
Did it help? ________________________
Is the accident you described the only cause of current discomfort? Yes ___ No ___
If No, why? _____________________________________________________________________
Are you suffering from any other disabling conditions? _______________________________
_______________________________________________________________________________
Have you had any other serious accidents causing any disability? _______________________
_______________________________________________________________________________

2. CURRENT MEDICAL COMPLAINTS
Currently I have pain in my:
Neck ___
Low Back ___
Mid Back ___
My pain began:
Gradually ___
Suddenly ___
I have pain:
Sometimes ___
Upper Back ___
Constant ___
My pain goes into my:
right leg ___
left arm ___
both ___
right arm ___
left arm ___
both ___
right leg ___
My pain is worse when I :
both ___
right arm ___
I have numbness or tingling:
left leg ___
left leg ___
both ___
cough ___
sneeze ___
sit ___
bend ___
walk ___
lift ___
push ___
pull ___
My pain wakes me up:
Yes ____
No ____
I have neck stiffness:
Yes ____
turn my head ___
No ____
Please describe any other symptom or condition which you are experiencing, or list any
Additional
comments:______________________________________________________________________

3. JOB DESCRIPTION
In a typical 8 hour workday (circle # hrs/activity):
Sit
Stand
Walk
Lift
Push/Pull
Reaching
0
0
0
0
0
0
-
1
1
1
1
1
1
2
2
2
2
2
2
-
4
4
4
4
4
4
4
4
4
4
4
4
-
6
6
6
6
6
6
6
6
6
6
6
6
-
8
8
8
8
8
8
hours
hours
hours
hours
hours
hours
I lift in Lbs:
Up to 20 lbs
20 to 40 lbs
40 lbs to 60 lbs
60 lbs or over
_____ Never
_____ Never
_____ Never
_____ Never
_______ Occasionally
_______ Occasionally
_______ Occasionally
_______ Occasionally
______Frequently
______Frequently
______Frequently
______Frequently
Do you use you hands for repetitive actions such as:
Simple Grasping
Firm Grasping
Fine Manipulating
Right Hand
Yes__
No__
Yes__ No__
Yes__
No__
Left Hand
Yes__
No__
Yes__ No__
Yes__
No__
Are you required to be around moving machinery?
Yes ___
No ___
Are you exposed changes in temperature or humidity?
Yes ___
No ___
Are you required to drive automotive equipment?
Yes ___
No ___
Please list any additional comments or concerns: _________________________________
_____________________________________________________________________________
_____________________________________________________________________________
______________________________
Signature
__________ ___________ ____________
Date