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K&D Electric
Home
Our Services
About
Employment Forms
Confidentiality Agreement
Direct Deposit
Employee Handbook
Employee Healthcare
Employee Withholdings State
Employee Withholdings w4
Equipment Agreement
Pre-Employment Application
Post Accident
Medical Info
Non-Compete
contact
Medical Info
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PRIOR INJURY AND DISABILITY QUESTIONNAIRE
Employee Name:
Employee Social Security Number:
Height:
Weight
Do you have any of the following?
.
Epilepsy (convulsions, seizures)
.
Diabetes (Medication Yes or No)
.
Cardiac (Heart) Disease
.
Meniscectomy (Inflammation of Cartilage of certain joints)
.
Amputation of foot, leg, arm, or hand
.
Total Loss of sight in one or both eyes, or a partial loss of corrected vision of more than 75% bilaterally
.
Polio
.
Cerebral Palsy
.
Multiple Sclerosis
.
Parkinson's Disease
.
Patellectomy (surgically removed knee cap)
.
Ruptured cruciate ligament (knee ligament)
.
One or more back or neck injuries or a disease process of the back or neck, substantiated by a doctor opinion and resulting in Disability over total of 120 or more days
.
Chronic Osteomyelitis (infection in bone)
.
Surgical or Spontaneous fusion of weight bearing joint
.
Hyperinsulinism
.
Muscular Dystrophy
.
Thrombophlebitis
.
Herniated Intervertebral Disk
.
Surgical Removal of an intervertebral disk or spinal fusion
.
Total Deafness
.
Hemophilia
.
Obesity (30% overweight)
Other:
2. Have you previously received workers compensation for an on the job injury?
3. Have you ever received a disability rating or had one assigned to you by an insurance company or state / federal agency?
4. Have you ever injured or sprained your back?
5. Have you ever injured or sprained your neck?
6. Have you ever injured or sprained your knee?
7. Have you ever had any type of surgery not mentioned above?
8. Do you have arthritis?
9. Medications?
.
Yes
.
No
.
Yes
.
No
.
Yes
.
No
.
Yes
.
No
.
Yes
.
No
.
Yes
.
No
.
Yes
.
No
.
Yes
.
No
If yes to above, give more details:
Employee's Name
Date:
Employee's Signature
Submit
