Repetitive Motion Questionnaire {SFN 50306}

REPETITIVE MOTION QUESTIONNAIRE CLAIMS DIVISION SFN 50306 (02/2015) 1600 E Century Ave, Ste 1 PO Box 5585 Bismarck ND 58506-5585 Telephone 800-777-5033 Toll Free Fax 888-786-8695 TTY (hearing impaired) 800-366-6888 Fraud and Safety Hotline 800-243-3331 www.workforcesafety.com Injured Worker's Name Body Part Claim Number Mailing Date PAGE 1 DIRECTIONS: PLEASE PRINT OR TYPE USING BLACK OR BLUE INK. Read and answer each question. If additional space is needed to respond, use the back of these pages or a separate sheet of paper. Please be sure to sign and date the last page and return this questionnaire to Workforce Safety & Insurance at the address listed above within 14 days from the mailing date listed above. Injured workers are subject to penalty for failure to comply or for any false statement. 1. a. Describe, as best you can, the motion/movements of your shoulder (s), arm(s), wrist(s), hand(s), and elbow(s) required by your job (including computer usage). b. How many hours/minutes per day/week do you spend performing the described movements? c. How long have you worked for your present employer? d. If employed with this employer less than one year, please list previous employer(s), how long employed with the previous employer(s), and a description of the job(s) performed at the previous employer(s). e. f. Do you operate any vibrating machinery? Yes No Have you always done this type of work (the current duties outlined in question 1a) for your employer? Yes No If you moved from another position in the company, please provide the details of the prior job, how long you were in the prior job, and when you moved to your current job. 2. a. b. Do you work more than one job or own a home-based business? Yes No If yes, please complete the following for each job. What is the name, address, and phone number of your employer? How long have you worked there? c. Please describe your work duties. d. Do you farm / ranch? Yes No American LegalNet, Inc. www.FormsWorkFlow.com C63 REPETITIVE MOTION QUESTIONNAIRE (con't) Claim Number Injured Worker PAGE 2 OF 4 3. a. b. Have you ever injured (i.e. fractured, sprained) your shoulder(s), arm(s), wrist(s), hand(s), or elbow(s) before? Yes No If yes, how many times? c. If yes, where did the injury occur? d. If yes, how did the injury occur? e. Explain, on a separate sheet if needed, any other details related to prior shoulder, arm, wrist, hand or elbow injuries. f. Have you ever treated previous symptoms on your own, such as using a brace, exercises, over the counter medications, etc? Yes No If yes, please explain . 4. a. b. Have you had any Electromyography (EMG)/Nerve Conduction tests? If yes, please list dates and results: Yes No 5. a. Do you experience any pain when bending your hand(s) forward? If yes, please explain: Yes No b. Do you experience any pain when bending your hand(s) backward? If yes, please explain: Yes No 6. a. Have you ever had x-rays taken for any reason on your shoulder(s), arm(s), wrist(s), hand(s) or elbow(s)? Yes No If yes, please explain: b Do you know of any x-ray findings that show a fracture in your shoulder(s), arm(s), wrist(s), hand(s) or elbow(s)? Yes No If yes, please explain: c. Do you know of any x-ray findings that show arthritis in your shoulder(s), arm(s), wrist(s), hand(s) or elbow(s)? Yes No If yes, please explain: American LegalNet, Inc. www.FormsWorkFlow.com C63 REPETITIVE MOTION QUESTIONNAIRE (con't) Claim Number Injured Worker PAGE 3 OF 4 Left 7. 8. a. What is your dominant hand? Right Have you had or do you have any hobbies, i.e. knitting, crocheting, cross-stitching, gardening, canning, piano? Yes No If yes, describe them and state how often you do them. b. How many hours a day do you play video or computer games? c. How many hours a day do you use your home computer? d. How many hours a day do you use your cellular phone/smart phone/tablet? 1. How many texts do you send per day? 9. a. Have you or do you participate in any sports, i.e. fishing, bowling, weightlifting, darts? If yes, describe the sport and how often you participate. Yes No b. Do you participate in a regular exercise program? Yes If yes, please explain the activity and frequency of the exercise. No 10. a. Have you ever been diagnosed as having, or maybe having, diabetes, kidney disease, liver disorder, thyroid disease, or alcoholism? Yes No If yes, explain: b. Please provide the names and addresses of all medical doctors or other health care professionals who have treated you for this condition. (Continue on back if needed.) Address City, State, Zip Phone Time Frame Complete Name Have you ever had any neck problems or injuries? Yes No If yes, please list any medical doctor, chiropractor, physical therapist, occupational therapist, or other health care professional that you treated with for your neck problems or injuries. (Continue on back if needed.) Complete Name Address City, State, Zip Phone Time Frame 11. 12. a. Have you ever been involved in an automobile accident? Yes If yes, what body part was injured and when did the accident occur? No b. Did you need to seek medical treatment for the auto accident? Yes No American LegalNet, Inc. www.FormsWorkFlow.com C63 REPETITIVE MOTION QUESTIONNAIRE (con't) Claim Number Injured Worker PAGE 4 OF 4 13. a. b. Have you ever been told that the pain in your shoulder(s), arm(s), wrist(s), hand(s) or elbow(s) is related to your work duties? Yes No If yes, what is the name of the physician who told you that your problem(s) was/were related to your work duties? c. What was the approximate date the physician told you? 14. Please provide any other information that may be helpful in determining the cause or extent of your pain or injury. 15. a. b. c. d. Women: Have you had any post menopausal symptoms or gynecological abnormalities? Yes No Have you taken oral contraceptives or similar hormones? Yes No Are you or have you been pregnant? Yes No If yes to question 15c, how long ago was your last pregnancy? 16. a. b. Have you had shoulder, arm, wrist, and/or elbow surgery(s)? Yes No If yes, what body part(s) (specify right or left)? When did you have the surgery? At what medical facility? c. If no, when do you expect to have surgery? At what medical facility? UPON COMPLETION OF THIS FORM, PLEASE SIGN, DATE, AND RETURN IT TO: Attn: Claims Department Workforce Safety & Insurance PO Box 5585 Bismarck, ND 58506-5585 Fraud Warning for Filing False Claims Any person claiming benefits or compensation from WSI who fi