Plaintiffs Chronological Medical History {105}

FORM 105 October 2016 Edition KENTUCKY DEPARTMENT OF WORKERS' CLAIMS PLAINTIFF'S CHRONOLOGICAL MEDICAL HISTORY Plaintiff Name Claim Number Include all injuries and major illnesses to the date of filing of the claim (Begin with most recent treatment) Name & Address of Physician or Hospital 1. Date Treatment Received Nature of Injury or Disease and Part of body affected? Still under a doctor's care? 2. 3. 4. 5. 6. I hereby certify that the above information is true and correct to the best of my knowledge and belief. Plaintiff's Signature Date American LegalNet, Inc. www.FormsWorkFlow.com