MEDICAL QUESTIONNAIRE
This questionnaire is intended to be used to identify conditions or impairments which may be registered with the Subsequent Injury Fund. This questionnaire may also be used to identify a worker's physical ability to perform the job he or she is being considered for.

Name:
Address:
Date of Birth:

SSN #:
E-mail:
Phone Number:

Have you ever had a work related injury ?YESNO

Have you ever suffered an injury or illness not related to work which required you to be off work or had to limit your activities for more than one week ?YESNO

Have you ever been in an automobile accident?YESNO

Please list your family physician and telephone number (if none please complete with N/A):
Physicians Name:
Physicians Phone:

Have you ever being treated or have been treated for by a physician ?YESNO

IMPORTANT: FALSE STATEMENTS OR REPRESENTATIONS MADE ON THIS QUESTIONNAIRE MAY CAUSE FORFEITURE OR WORKERS' COMPENSATION BENEFITS UNDER THE PROVISIONS OF 52-1-283 OF THE 1991 WORKERS' COMPENSATION ACT, PROVIDED THE WORKER KNOWINGLY AND WILLFULLY CONCEALED INFORMATION OR MADE A FALSE REPRESENTATION OF HIS OR HER MEDICAL CONDITION.
I hereby certify that the information contained on this medical questionnaire is correct and true and understand the above statement concerning the information contained within this document.
Please make sure that this entire questionnaire is complete before signing.

Employee Signature:

Current Date:

Witness Signature:

Current Date: