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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information, including your birthdate, name, address, and contact details. Ensure accuracy as this information is crucial for your health records.
Next, provide details about your employer and primary care physician. Fill in their names, addresses, and contact numbers to facilitate communication regarding your health.
In the section marked 'MARK AN X ON THE PICTURE WHERE YOU HAVE PAIN OR OTHER SYMPTOMS', use the drawing tools available in the editor to indicate areas of discomfort.
Describe your current problem and how it began in the designated text fields. Be specific about symptoms and their onset for better assessment.
Indicate whether the issue is work-related or auto-related by selecting the appropriate option. This helps in determining coverage for treatment.
Complete the pain scale section by selecting a number that reflects your current pain level. This visual representation aids healthcare providers in understanding your condition.
Finally, review all entered information for accuracy before signing at the bottom of the form. Your signature confirms that all details are correct.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (142 Votes)
2012	4.1 Satisfied (49 Votes)
2006	4.3 Satisfied (142 Votes)

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