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