Narendra Kansal, MD

PLEASE FILL OUT THE BELOW COMPLETELY. EVERYTHING IS REQUIRED, IF SOMETHING DOES NOT APPLY TO YOU, PLEASE PUT N/A.

NAME * HOW WILL/DID YOU GET TO THE OFFICE FOR YOUR APPOINTMENT? * IF BY CAR, DID/WILL YOU DRIVE YOURSELF? *

HISTORY

DESCRIBE BRIEFLY HOW THE ACCIDENT/INJURY OCCURRED * WHAT AREA(S) OF YOUR BODY WAS (WERE) INJURED? * WHAT MEDICAL CARE OCCURRED THE DAY OF THE ACCIDENT/INJURY? * DID YOU GO TO THE HOSPITAL? * IF YES, WHAT HOSPITAL? * WERE YOU ADMITTED? * IF YES, FOR HOW LONG? * IS AN ATTORNEY OR A LICENSED REPRESENTATIVE REPRESENTING YOU? * IF YES, NAME, ADDRESS, PHONE # AND FAX # OF REPRESENTATIVE: *

TREATMENT

PLEASE LIST THE HEALTH CARE PROVIDERS YOU HAVE SEEN FOR THIS INJURY. PLEASE INDICATE THEIR SPECIALTY. * DESCRIBE ANY TREATMENT YOU HAVE UNDERGONE (INCLUDE PHYSICAL THERAPY, ACUPUNCTURE, SURGERY, CHIROPRACTIC ADJUSTMENTS, ECT.) * PLEASE IDENTIFY ANY MEDICATIONS YOU HAVE TAKEN FOR THIS INJURY * HAVE YOU BEEN GIVEN ANY MEDICAL EQUIPMENT FOR HOME USE? *

WORK HISTORY

ARE YOU CURRENTLY WORKING? * WHO IS YOUR EMPLOYER? * WHAT IS YOUR JOB TITLE? * WAS ANY TIME LOST FROM WORK DUE TO THIS INJURY? * IF YES, PLEASE PROVIDE DATES * ANY RESTRICTED DUTY? * DESCRIBE ANY TYPE OF WORK YOU ARE CURRENTLY DOING (INCLUDING RESTRICTIONS) * IF YOU ARE NOT WORKING WHAT SPECIFICALLY DO YOU FEEL PROHIBITS YOU FROM RETURNING TO WORK? *

PRESENT COMPLAINTS

LIST ALL SYMPTOMS AND COMPLAINTS RELATED TO THIS INJURY *

PAST MEDICAL HISTORY

HAVE YOU HAD ANY PRIOR MOTOR VEHICLE ACCIDENTS? IF YES, PLEASE PROVIDE DATES & INJURIES * HAVE YOU HAD ANY PRIOR WORKERS COMPENSATION INJURIES? IF YES, PLEASE PROVIDE DATES AND INJURIES * HAVE YOU UNDERGONE ANY PREVIOUS SURGERY? IF SO, PLEASE PROVIDE DATES AND TYPE OF SURGERY *

DAILY LIVING

WHAT ACTIVITIES ARE YOU ABLE TO PERFORM AND WHAT ACTIVITIES ARE YOU UNABLE TO PERFORM? (I.E HOW LONG CAN YOU STAND, SIT, AND LIE DOWN?) * WHAT DAILY ACTIVITIES ARE YOU CAPABLE/INCAPABLE OF PERFORMING (I.E COOKING, CLEANING, TENDING TO PERSONAL HYGIENE, TAKING CARE OF CHILDREN, SHOPPING, ECT) * HOW DO YOU SPEND YOUR AVERAGE DAY? * SIGNATURE * DATE *