Work Cover Questionnaire

Please use this form to provide us some information pertaining to your work-cover claim in advance of your appointment.
You may also download this form at the bottom of the page and provide it to reception.

Name

First Name

Last Name

Date of Birth

YYYY

Phone Number

Occupation

Employer

How long have you been with this employer?

Workplace Cover Claim No and Case Manager (if applicable)

How many claims have you had to date?

Please provide details for each.

How did the injury occur?

What was the date of your injury?

YYYY

Where at work did your injury occur?

What treatment have you received so far?

Medication

Physiotherapy

Injections

Surgery

Other:

How many days have you had off work?

Are you currently on restricted duties? If so, what are they?

Is the injury a new problem, or an exacerbation of a previously existing one?

What medical problems do you have?

Do you smoke?

Yes

Thank you for taking time to complete this questionnaire; if you have any further details pertinent to your claim that you'd like to discuss, please don't hesitate to mention them to me at your appointment.

Download the work cover questionnaire

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Work Cover Questionnaire

Download the work cover questionnaire

BONE + JOINT CLINIC