MusculoSkeletal Questionnaire Application Supplement - Individual Disability - ICC16, 17985 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information, including your name and birth date, in the designated fields.
3. In Section 1, provide detailed information about any musculoskeletal issues you've experienced in the last 10 years. Include dates of consultations and diagnoses.
4. If applicable, indicate whether you have had surgery for these conditions in Section 2. Fill out the details regarding the type of surgery and hospital information.
5. In Section 3, specify any medications you have used related to your conditions. Include dosage, frequency, and prescribing professional's details if different from those listed earlier.
6. Section 4 requires you to disclose if you've missed more than four consecutive workdays due to these conditions. Provide relevant dates and details.
7. Finally, use Section 5 for any additional remarks or information that may be pertinent to your application.
8. Review all entries for accuracy before signing at the bottom of the form. Ensure all required fields are completed.

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