Occupational Injury History Form

This occupational injury history form provides comprehensive documentation of work-related injuries, illnesses, and exposures throughout an individual's employment history. Occupational health providers can systematically record injury details including mechanism of injury, body parts affected, treatment received, time away from work, modified duty assignments, and functional outcomes. The form captures essential information for workers compensation evaluations, fitness-for-duty assessments, pre-placement physicals, and disability determinations while ensuring compliance with OSHA recordkeeping requirements.

Designed for occupational medicine clinics, industrial health programs, workers compensation evaluators, employee health departments, and disability assessment providers, this template ensures thorough documentation of workplace injury patterns and outcomes. It supports identification of recurring injury risks, evaluation of previous treatment effectiveness, assessment of current functional limitations, and informed decision-making regarding work capacity and appropriate job accommodations. The form facilitates continuity of care and helps providers make evidence-based recommendations for safe return-to-work planning.