TELEMEDICINE PRE SCREENING QUESTIONNAIRE FOR INJURY EVALUATION

TELEMECINE PRE SCREENING FOR INJURY EVALUATION

Welcome to the Workers Comp Injury Telemedicine Evaluation Process.

Complete the form below. VERY IMPORTANT: Every Field must be completed. (You will not be able to submit the form unless it is completed)
If you are completing this as a New Work Injury Patient, complete the NEW INJURY Telemedicine Evaluation Form Below
If you are a Returning Patient doing a Follow-Up visit, complete the FOLLOW-UP Telemedicine Evaluation Form Below.
Once the corresponding form is fully completed, Click the Send Message Button
Once you submit the form, click on the Calendar Button to schedule the Telemedicine Evaluation. Please keep in mind that many people are trying to get evaluated. When the Calendar opens, only available times will display. Choose from the times that are displayed.
ON THE DAY OF YOUR APPOINTMENT:
Enter the Telemedicine waiting room 5 minutes PRIOR to your appointment. Please do not be late!
(to enter the telemedicine waiting room Click the "CLICK HERE TO START YOUR TELEMEDICINE APPOINTMENT" button on the home page)
You will be placed in the waiting room until the Provider enters the evaluation room.
During this initial call, your questionnaire will be reviewed with you. The Provider will ask detailed questions based on you answers.
This will help the provider to make treatment decisions for your Workers Comp Injury.
You and your employer will both receive a copy, via email, of your work status report that will detail the instructions on your work status (modified duty vs. full duty)

*Before proceeding with the new injury telemedicine evaluation process, please click on the button below for the evaluation and treatment agreement and then complete the agreement form

DOWNLOAD TELEHEALTH PATIENT AGREEMENT

Agreement Form

Complete this Section for Follow-Up Telemedicine Evaluation

Para leer esta página en español, haga clic en el enlace del traductor arriba

Covid-19 Evaluation Form

Name*

Phone*

2. Any changes in your overall health since your last visit?*

3. Any side effects from your medications?*

3a. If Yes, please explain:

4. What is your pain level BEFORE you take your medication(s)?

5. What is your pain level BEFORE you take your medication(s)?*

6. How long does your medications control your pain? (Please indicate how many hours)

7. How would you describe your pain (please pick all that apply)?

8. Is your pain(s):

9. When you take your medications are you able to sleep at night?

10. Is your condition Worse, Better or the Same SINCE YOUR LAST VISIT?

11. Any problems performing your current work duties?)

12. Have you had any other visits with any other doctor SINCE YOUR LAST VISIT?

Yes

13. Any changes in your Medical History?

14. Any changes in your Work History?

15. Are you currently having Physical therapy treatments?

15a. If YES, How many?

16. Do you have any upcoming Diagnostic Tests or Medical Appointments scheduled?

17. Since your injury, have you been performing your regular duties?

At Total Work Care Injury Clinic we have tried to make you workers comp evaluation as easy as possible by providing this telemedicine program. Once you complete the form, you must make an appointment on our special Telemedicine Appt. For FOLLOW-UP Evaluation Calendar . Please click on the button below and request your virtual appointment...Thank You!

TELEMEDICINE WAITING ROOM

Complete this Section for New Injury Telemedicine Evaluation

If this is a follow-up appointment, please go to the section.

Para leer esta página en español, haga clic en el enlace del traductor arriba

Covid-19 Evaluation Form

Name*

Phone:

Email:

Name of Company

Please provide the Name of Your Pharmacy - Include City & Street and Phone Number

1. Date of Injury

2. Job Description

3. Job Duties

4. Do you regularly lift at work?

5.Length of time with current employer

6. Date of Injury

7. Please list the Parts of your Body that you have injured?

8. What is your current pain level (on an scale of 0-10)?

9. Mechanism of injury/How did you get injured- Please be as detailed as possible:

10. Any allergies to medications or food? (If Yes Please List, If None Write No)

11. Any past injuries to these same body part? YES/NO

12. Have you taken any medications for this injury?

12a. If YES please list medications

13. Is your condition Worse, Better or the Same since the injury happened?

14. Do you have any upcoming Diagnostic or Medical Appointments scheduled?

15. Since your injury, have you been performing your regular duties?

16. Check ALL That Apply:

a. Radiation of Pain

b. Numbness, Tingling

c. Weakness

d. Muscle Spasms

e. Insomnia

17. Are you still working with this Injury?

At Total Work Care Injury Clinic we have tried to make you workers comp evaluation as easy as possible by providing this telemedicine program. Once you complete the form, you must make an appointment on our special Telemedicine Appt. For Workers Comp NEW Injury Calendar . Please click on the button below and request your virtual appointment...Thank You!

TELEMEDICINE WAITING ROOM

Online Forms

Click the button below to get form for DMV Handicap Permit Request

DMV HANDICAP REQUEST FORM

DOCTOR EVALUATION

CLICK HERE

TELEMECINE PRE SCREENING FOR INJURY EVALUATION

Welcome to the Workers Comp Injury Telemedicine Evaluation Process.

Agreement Form

Complete this Section for Follow-Up Telemedicine Evaluation

Para leer esta página en español, haga clic en el enlace del traductor arriba

Covid-19 Evaluation Form

Complete this Section for New Injury Telemedicine Evaluation

If this is a follow-up appointment, please go to the section.

Para leer esta página en español, haga clic en el enlace del traductor arriba

Covid-19 Evaluation Form

Online Forms

DOCTOR EVALUATION

Helpful Links

Business Info

Office Hours