Medical History Checklist

I M A G E I N C O N F I D E N T I A L F O L D E R

Medical History Checklist Ohio Bureau of Workers’ Compensation

PleaseInjured Worker complete Name: the following medical checklist. If you answer yes to anyClaim of the Number questions (s): below, please provide further information about the condition(s), any treatment you received or are receiving for the condition(s) as well as the names and addresses of any doctor(s), clinic(s) or hospital(s) from whom you have received treatment (including prescriptions) in the space provided below, or on a separate sheet.

Do you currently have, have you had, or have you been diagnosed or treated for any of the following: Yes No Yes No

Diabetes Lupus Arteriosclerosis Amyloidosis Deep Vein Thrombosis/Phlebitis Rheumatoid Arthritis Buerger’s Disease/Peripheral Arterial Disease Any Other Autoimmune Disorder

Aneurysm Hemophilia

Heart Disease Anemia

Heart Attack Sickle Cell Disease

Angina Any other Blood Disease or Disorder Congestive Heart Failure Crohn’s Disease Any Other Heart/Cardiac Condition(s) Ulcerative Colitis

Asthma Any Other Gastrointestinal Disease Chronic Bronchitis Meningitis Emphysema Multiple Sclerosis Chronic Obstructive Pulmonary Disease (COPD) Muscular Dystrophy

Cystic Fibrosis Epilepsy

Asbestosis Parkinson’s Disease

Silicosis Progressive Motor Neuron Disease (ALS/Lou Gehrig’s) Mesothelioma Stroke/CVA/Transient Any Other Lung Disease or Ischemic Attack Condition Affecting the Lungs Cerebral Palsy Cancer Huntington’s Chorea Hepatitis Alzheimer’s/Dementia Cirrhosis of the Liver or Other Liver Disease Tuberculosis

Kidney/Renal Disease Organ Transplant

Medical History Checklist (Rev. 03/26/08). Page 1 of 2 HIV/AIDS

I M A G E I N C O N F I D E N T I A L F O L D E R

Any other illness, condition, or disease process not listed above that would shorten your life expectancy.

Please list: ______.

______.

If you answered yes to any of the above questions please provide further information about the condition(s), any treatment you received or are receiving for the condition(s), as well as the names and addresses of any doctor(s), clinic(s), or hospital(s) from whom you have received treatment (including prescriptions) in the space provided below, or on a separate paper, if extra space is necessary:

______

______Injured Worker’s Signature Date

Certification

I have reviewed the answers to the above Medical History Checklist with my client for completeness and accuracy. I have personally explained to my client that inaccurate or incomplete answers may constitute fraud, are grounds for the immediate dismissal of his/her settlement application, and may render a final settlement void.

Medical History Checklist (Rev. 03/26/08). Page 2 of 2 ______Attorney’s Signature Date

Medical History Checklist (Rev. 03/26/08). Page 3 of 2