Integrity IME Injury Form

Injury History for Worker's Comp, Motor Vehicle Accidents or Third Party Liability Injury

Joan Takacs, D.0., John Takacs, D.O.
Today’s Date

MonthDayYear
Date of Injury*

MonthDayYear
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Age
Type of Injury*

WorkAutoHomeOther
Describe your current symptoms or reason for visit:*
Describe what happened when the injury occurred or pain started:*
Employer
Usual Occupation
Date of Hire

MonthDayYear
Briefly describe your job:
Current working:

Regular DutyLight Duty
Describe:
Please fill out the pain diagram. Shade painful body regions to show where the pain is. Apply "X" for numbness/tingling areas. We will have you fill in the diagram at the time of your visit.
For Auto Injury

You were the DriverPassenger
Vehicle Ownership

PersonalWork
Seat Belt On

YesNo
Type of Vehicle

CarPick-up or VanMotorcycleBusBicylePedestrian
Have you injured this area/areas before?

YesNo (if yes briefly describe)
Describe:
Previous Work or Motor Vehicle injuries or claims

YesNo
Brief description

DateCondition
Residual Issues

YesNo
Add more date
Brief Description

DateCondition
Residual Issues

YesNo
Add more date
Biref Description

DateCondition
Residual Issues

YesNo
Any prior treatment to the same area?

YesNo (if yes explain)
Explain:
Are you currently on a pain contract with another provider?

Yes (Please fill out)No
Provider
Medication and Dose
List the names of all doctors, chiropractors, physicaltherapists, massage therapists, counselors, etc. you have seen for this condition:
1.
2.
3.
4.
5.

Diagnostic tests done for your problem:

	Approx Date	Facility
X-ray (body part)
CT (CAT Scan)
MRI
Bone Scan
EMG/Nerve conditions
Surgeries
Injections

List all medications tried previously for this condition. Was this medication helpful?
medication name
Helpful?

YesNo
medication name
Helpful?

YesNo
medication name
Helpful?

YesNo
medication name
Helpful?

YesNo
medication name
Helpful?

YesNo
medication name
Helpful?

YesNo
Current exercise (briefly describe)

StretchingStrengtheningAerobicNone
Describe:
How many days a week?
For how long?
What recreational or other activities are important to you that you cannot do as a result of this injury?

0/100
Should be Empty:

Injury History for Worker's Comp, Motor Vehicle Accidents or Third Party Liability Injury