IME Patient Intake Form

Patient's Name

Date of Birth

Age

Date of Injury

Claim #

Please fill in/check the appropriate answers to the following:

Education completed

Less than 12th Grade GED High School Graduate Two-Year Degree Bachelor Degree Master Degree

Military History

Branch of service

Work History

Occupation

Current Employer

Employer at time of injury

How long with company

Occupation at time of injury

Please list the year and type of any:

Surgery

Past Surgery

Health History

If yes, When?

If yes, What kind?

If yes, How Often?

Please list all types

Do you have a history of:

Please Explain

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Patient's Name / Signature

Date

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