Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Occupational Injury History Form
Employee Full Name
Current Employer
Job Title and Duties
Date of Injury
____ / ____ / ________
Body Part Injured
Mechanism of Injury
Treatment Received
Time Away From Work
Current Work Status
- Working as usual
- Working with restrictions
- Not currently working
- Retired
- Other
Previous Workplace Injuries
Occupational Injury History Form template from formisoft.com. formisoft.com/intake-templates/occupational-injury-history