PHYSIOTHERAPY CHIROPRACTIC MASSAGE I LASER THERAPY I CUSTOM ORTHOTICS SHOCKWAVE THERAPY
WCB Questionnaire
Client Name
Claim No (if known)
Employer's Name
Employer's official address
Name of your Supervisor
Supervisor's Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Injury
/
Month
/
Day
Year
Date
Client's Job Title
AHN number
1. Your WCB Case Manager
Phone Number
Format: (000) 000-0000.
2. When you injured yourself, did you experience discomfort immediately?
Yes
No
3. Did you see a medical Doctor immediately:
No
Yes (Emergency)
Yes (Walk-in clinic)
Yes (family Doctor)
4. If no, when did you see a Doctor?
-
Month
-
Day
Year
Date
5. Do you have a Doctor’s referral for physical Therapy?
Yes
No
6. Did your attending Doctor’s complete WCB Report?
Yes
No
7. Have you had injury before?
Yes
No
8. Did you complete and send the WCB incident report?
Yes
No
9. Did your employer complete WCB incident report?
Yes
No
10. Have you missed work due to your injury?
Yes
No
11. Are you currently working?
Yes
No
12. Are you required to frequently lift/pull/push:
0 - 10 lb
11 - 25 lbs
26 - 50 lbs
51 – 100
over 100 lbs
Type option 6
13. Are you required to occasionally lift/pull/push:
0 - 10 lb
11 - 25 lbs
26 - 50 lbs
51 – 100
over 100 lbs
Not Required
14. What are you currently able to lift/pull/push:
0 - 10 lb
11 - 25 lbs
26 - 50 lbs
51 – 100
over 100 lbs
Not Required
15. Are you on modified duties?
Yes
No
16. Do you feel your injuries are limiting you at work?
Yes
No
Patients Signature
Date
/
Month
/
Day
Year
Date
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