<p> 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 </p><p>Medical History Checklist Ohio Bureau of Workers’ Compensation</p><p>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. </p><p>Do you currently have, have you had, or have you been diagnosed or treated for any of the following: Yes No Yes No</p><p>Diabetes Lupus Arteriosclerosis Amyloidosis Deep Vein Thrombosis/Phlebitis Rheumatoid Arthritis Buerger’s Disease/Peripheral Arterial Disease Any Other Autoimmune Disorder </p><p>Aneurysm Hemophilia </p><p>Heart Disease Anemia </p><p>Heart Attack Sickle Cell Disease </p><p>Angina Any other Blood Disease or Disorder Congestive Heart Failure Crohn’s Disease Any Other Heart/Cardiac Condition(s) Ulcerative Colitis </p><p>Asthma Any Other Gastrointestinal Disease Chronic Bronchitis Meningitis Emphysema Multiple Sclerosis Chronic Obstructive Pulmonary Disease (COPD) Muscular Dystrophy </p><p>Cystic Fibrosis Epilepsy </p><p>Asbestosis Parkinson’s Disease </p><p>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 </p><p>Kidney/Renal Disease Organ Transplant </p><p>Medical History Checklist (Rev. 03/26/08). Page 1 of 2 HIV/AIDS </p><p>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</p><p>Any other illness, condition, or disease process not listed above that would shorten your life expectancy.</p><p>Please list: ______.</p><p>______.</p><p>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:</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______Injured Worker’s Signature Date</p><p>Certification</p><p>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. </p><p>Medical History Checklist (Rev. 03/26/08). Page 2 of 2 ______Attorney’s Signature Date</p><p>Medical History Checklist (Rev. 03/26/08). Page 3 of 2</p>