LA Works Employee Medical Questionnaire

1001 North 23rd Street
Post Office Box 44187

Baton Rouge, LA 70804-4187
(O)
(F)
225-342-7866
800-201-2493
225-219-5968
Bobby Jindal, Governor

Curt Eysink, Executive Director
Office of Workers Compensation Administration

Second Injury Board
LAOWCASecondInjuryBoardKnowledgeQuestionnaire
Thefollowingquestionnaireshouldonlybecompletedbyindividualsthathavebeenhiredforemployment.
Youremployermayaskthatyoucompletethisquestionnairefollowingyourinitialhireandperiodically
thereafter.
ThequestionnairemaybeusedintheestablishmentofpriorknowledgeforthepurposeofobtainingSecond
InjuryFundrelieffromtheSecondInjuryBoard.TheSecondInjuryBoardmayreimburseyouremployerfor
workerscompensationclaimsthatmeetcertaincriteriashouldyoubecomeinjuredonthejob.This
reimbursementinnowayaffectsthebenefitsowedtoyoubyyouremployerortheirinsurancecompany
undertheLouisianaWorkersCompensationAct,La.R.S.23:10211361.
WARNING
FAILURETOANSWERTRUTHFULLYAND/ORCORRECTLYTOANYOFTHEQUESTIONSONTHIS
FORMMAYRESULTINAFORFEITUREOFYOURWORKERSCOMPENSATIONBENEFITSUNDER
LAR.S.23:1208.1.
Employer: _________________________________________________________________________________
EmployeeName:____________________________________________________________________________
DateofBirth(mm/dd/yyyy): ____________
Male:
Female:
Soc.Sec.#(last4digitsonly): ____________
HomeAddress: _____________________________________________________________________________
TelephoneNumber:( ____ ) __________________
EmployeeSignature: ________________________________________
Date: _________________________
EmployerWitness: _________________________________________
Date:_________________________
PAGE _____ OF______
SIBFORMD12/10
|
Equal Opportunity Employer/Program
www.laworks.net
Auxiliary aids and services are available upon request to individuals with disabilities TDD# 800-259-5154
Pleaseplaceacheckintheappropriateboxnexttoeachmedicalconditionlistedbelow.Eachillnessorcondition
requiresaYes(Y)orNo(N)answer.Forallconditionsthatyoucheckyes,writeabriefexplanationontheExplanation
Page.
DiseaseandOtherMedicalConditions[Pleasechecktheappropriatebox.Eachillness/injuryrequiresaYes(Y)orNo(N)answer.]
Y N
Diabetes
Silicosis
VaricoseVeins
Asbestosis
Hyperinsulinism
Alzheimers
Emphysema
HearingLoss
COPD
Hypertention
HeadInjury
Epilepsy
Stroke
Y N
CerebralPalsy
Tuberculosis
MultipleSclerosis
PostTraumaticStress
Osteomyelitis
NervousDisorder
MuscularDystropy
MigraineHeadaches
MentalRetardation
KidneyDisorder
LossofUseofLimb
SeizureDisorder
SickleCellDisease
Y N
Arthritis
Parkinsons
BrainDamage
Asthma
Dementia
Thrombophlebitis
Arteriosclerosis
Hodgkins
Cancer
DoubleVision
MentalDisorders
Hemophilia
BleedingDisorder
Y N
HeartDisease/HeartAttack
CongestiveHeartFailure
VisionLoss,oneorbotheyes
DisabilityfromPolio
PsychoneuroticDisability
RupturedorHerniatedDisc
AnkylosisorJointStiffening
High/LowBloodPressure
CarpalTunnelSyndrome
CompressedAirSequelae
DiseaseoftheLung
CoronaryArteryDisease
HeavyMetalPoisoning
SurgicalTreatment[Pleasechecktheappropriatebox.Eachillness/injuryrequiresaYes(Y)orNo(N)answer.]
Y N
SpinalDiscSurgery
Year(approximateifunsure)___________
SpinalFusionSurgery
Year(approximateifunsure)___________
AmputatedFoot
Left
Right
Year(approx.ifunsure) ___________
AmputatedLeg
Left
Right
AmputatedArm
Left
Right
AmputatedHand
Left
Right
KneeReplacement
Left
Right
HipReplacement
Left
Right
OtherJointReplacement
Joint ________________________ Year ________________
OtherSurgicalProcedure
Procedure ___________________ Year ________________
Date: _________________________
Date:_________________________
PAGE _____ OF______
SIBFORMD12/10
EXPLANATIONPAGE
Pleaseusethespacebelowtoexplaintheillnessesand/orconditionsthatyoucheckedaYes(Y)oranyothermedical
conditionsthatmaynotbelistedonthisform.Askyouremployerforadditionalcopiesofthispageifneeded.
CONDITION: ____________________________________________________ YearDiagnosed(approx):_______________

Areyoustilltreatingforthiscondition?
Yes
No
Areyoutakingmedicationforthiscondition?
Yes
No
Doyouhaveanypermanentrestrictionsforthiscondition?
Yes
No
BriefExplanation: ___________________________________________________________________________________

Yes
No
Yes
No
Yes
No

Yes
No
Yes
No
Yes
No

Yes
No
Yes
No
Yes
No
Date: _________________________
Date: _________________________
PAGE _____ OF______
SIBFORMD12/10
Pleaseanswerthefollowingquestions.
1.
Hasanydoctoreverrestrictedyouractivities?
Yes No
IfYes,pleaselisttherestrictions: __________________________________________________________
Weretherestrictions:Permanent____Temporary____
Areyoucurrentlyrestricted?
Yes No
Whatisthemedicalconditionforwhichyouarerestricted? ______________________________________
2. Areyoupresentlytreatingwithadoctor,chiropractor,psychiatrist,psychologistorotherhealthcare
provider?
Yes No
Pleaselistthemedicalconditionbeingtreated: ________________________________________________
DoctorsName: ________________________________Specialty:__________________________________
DoctorsAddress: ________________________________________________________________________
3. IfyouarepresentlytakingprescriptionmedicationotherthanthoselistedontheExplanationPage,please
completetherequestedinformationbelow.
Medication: ___________________________________PrescribingDoctor: __________________________
Medication: ___________________________________PrescribingDoctor: __________________________
4. Haveyoueverhadanonthejobaccident?
Yes No
IfyouansweredYES,pleaseprovidethedateforeachinjuryandthenatureoftheinjury:
_______________________________________________________________________________________
Howlongwereyouoncompensation? _________________________
NameofEmployer: _______________________________________________________________________
5. Hasadoctorrecommendedasurgicalprocedure,whichhasnotbeencompletedpriortothisdate,
includingbutnotlimitedtoknee,hiporshoulderreplacement?
Yes No
IfyouansweredYES,pleaseprovide:
Recommendedsurgery: _____________________________________
Approximatedateofrecommendation:_________________________
DoctorsName: ________________________________Specialty:__________________________________
DoctorsAddress: ________________________________________________________________________
Date: _________________________
Date: _________________________
PAGE _____ OF______
SIBFORMD12/10
WARNING
FAILURETOANSWERTRUTHFULLYAND/ORCORRECTLYTOANYOFTHEQUESTIONSONTHIS
FORMMAYRESULTINAFORFEITUREOFYOURWORKERSCOMPENSATIONBENEFITSUNDER
LAR.S.23:1208.1.
Ihavecompletedthisformhonestlyandtothebestofmyknowledge.Iunderstandthatprovidingfalse
informationoromittingpertinentinformationcouldresultinlossofmyworkerscompensationbenefits
shouldIbecomeinjuredonthejob.
Date: _________________________
EmployeePrinted:_________________________________________
Iamanauthorizedrepresentativeoftheemployerdesignatedtoobtainandreviewtheinformation
providedbytheemployeeonthisquestionnaire.Ihaveconfirmedthattheemployeeunderstandsthe
consequencesassociatedwithprovidingfalseinformationoromittingpertinentinformation.Ihave
confirmedthattheemployeeisabletoreadandunderstandtheinformationprovidedonthisquestionnaire
orIhavepersonallyreadthequestionnairetotheemployee.Ihaveprovidedtheemployeewithasmany
copiesoftheExplanationPageasneeded.Ihaveconfirmedthenumberofandlabeledthepagesofthis
questionnaire.
Date: _________________________
EmployerWitnessPrinted: ____________________________________________________________________
Title: _____________________________________________________________________________________
PAGE _____ OF______
SIBFORMD12/10

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1001 North 23rd Street

Post Office Box 44187

Bobby Jindal, Governor

Office of Workers Compensation Administration

PAGE _ OF__

Equal Opportunity Employer/Program

Joint ________ Year

Procedure ___ Year

PAGE _ OF__

CONDITION: ______________________________________ YearDiagnosed(approx):_

CONDITION: ______________________________________ YearDiagnosed(approx):_

CONDITION: ______________________________________ YearDiagnosed(approx):_

CONDITION: ______________________________________ YearDiagnosed(approx):_

PAGE _ OF__

Medication: _________PrescribingDoctor:

Medication: _________PrescribingDoctor:

PAGE _ OF__

PAGE _ OF__

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