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MEDICAL DATA:

32. Nature of injuries __________________________________________________

____________________________________________________________________

Detailed Injuries

33. I. Central Nervous System

Headaches___________________________________________________________

Memory Loss_________________________________________________________

Personality Changes

Anxiety______________________________________________________________

Depression____________________________________________________________

Mood swings__________________________________________________________

Loss of impulse control__________________________________________________

Irritability sleep disorder_________________________________________________

Appetite changes_______________________________________________________

Eyes_________________________________________________________________

Ears-Ringing__________________________________________________________

PNS

Numbness and tingling extremities_________________________________________

34. II. Chronic Fatigue, Fibromylagia, Chemical Sensitivity

Sensitive to other chemicals, gasoline, smoking, solvents, pesticides, perfume

_____________________________________________________________________

_____________________________________________________________________

Fatigue, tiredness and muscle fatigue________________________________________________________________

35. III. Respiratory

Upper and Lower________________________________________________________

Shortness of breath, trouble breathing with or without exposure

36. IV. IMMUNE/ AUTOIMMUNE

Fatigue, illnesses, flu____________________________________________________________________

37. V. ENDOCRINE

Thyroid, adrenal, pituitary__________________________________________________

38. VI. LIVER

Blood testing____________________________________________________________

Related mcs____________________________________________________________

39. VII. GI

______________________________________________________________________

40. VIII. RASHES, ALLERGIES

______________________________________________________________________

41. IX. CANCER

42. DO YOUR SYMPTOMS SEEM TO BE AGGRAVATED BY A SPECIFIC ACTIVITY?_____________________________________________________________

______________________________________________________________________

43. HAVE THERE BEEN ANY INCIDENCES OF BIRTH DEFECTS SINCE THE EXPOSURE/OCCURRENCE? PLEASE EXPLAIN. _________________________

_____________________________________________________________________

44. Names and addresses of current treating physicians:

1. ___________________________________________

2. ___________________________________________

3. ___________________________________________

45. Hospital care _____________________________________________

___________________________________________________________

46. X rays _____________________________

47. Diagnostic testing___________________________________________________

_____________________________________________________________________

48. Previous traumatic injuries:

1. __________________________________

2. __________________________________

3. ___________________________________

49. Previous NON traumatic injuries:

1. _____________________________

2. _____________________________

3. ________________________________

50. Name and address of family physician _________________________________

______________________________

51. Date of last visit _________________

52. Reason for visit __________________

53. Current medical program, if any ___________________________________

PERSONAL INTERESTS:

54. Hobbies ______________________________________________________

55. Educational background _________________________________________

56. Remarks ______________________________________________________

_________________________________________________________________

_________________________________________________________________

ATTACHMENTS:

1.

2.

3.

4.

5.

EMPLOYMENT HISTORY:

57. Name and address of present employer(or if disabled, last employer) _____________________________

______________________________________________________

58. Job classification ____________________

59. Length of employment _______________

60. Union ___________________

61. Base pay at date of accident hourly__________ weekly___________

62. Annually __________ Bonus and overtime ________________

63. Hours per week _______

64. Commissions (if any ____________

65. Date stopped work _____________

66. Date returned to work __________

67. PART TIME EMPLOYMENT (NAME AND ADDRESS). IF SELF EMPLOYED, PLEASE STATE

________________________________________________

_______________________________________________

68. Earnings:

Weekly ___________ Monthly _____________ Annually ________________

69. Prior employment _____________________________________________

70. Disability benefits______________________________________________

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