Commercial Electrical Contractor Since 1994 • SBE Certified [email protected]

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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

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Call us at 678-673-6714 or reach out online. From design-build to installation, we deliver reliable electrical and HVAC systems.

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Commercial electrical contractor serving Georgia and Florida since 1994. SBE Certified.

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678-673-6714

[email protected]

55 Hwy 85 Suite 200, Senoia, GA 30276

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