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Practice name: ______________________________
Workers' Compensation Intake Form
Workers' Compensation Intake Form This form is used to document your workplace injury for workers' compensation purposes. Please provide accurate and complete information, as it will become part of your official claim record.
Full Name *
Date of Birth *
____ / ____ / ________
Email Address *
Phone Number *
Employer Name *
Occupation *
Employer Phone Number
Injury Details & Claim Information Please describe the circumstances of your workplace injury and provide your claim details.
Date of Injury *
____ / ____ / ________
Time of Injury *
____ : ____ AM / PM
Location Where Injury Occurred *
Describe How the Injury Occurred *
Body Parts Injured *
- Head
- Neck
- Shoulder
- Arm
- Elbow
- Wrist
- Hand
- Back
- Hip
- Knee
- Ankle
- Foot
Symptoms *
- Pain
- Swelling
- Numbness
- Weakness
- Limited Range of Motion
- Bruising
Current Pain Level (1-10) *
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Was the Injury Reported to Your Employer? *
- Yes
- No
Workers' Comp Claim Number
Workers' Comp Insurance Carrier
Treating Physician
Previous Workplace Injuries
Current Medications
Workers' Compensation Intake Form template from formisoft.com. formisoft.com/intake-templates/workers-comp-intake