Fill and Sign the Repetitive Trauma Form

YesNo Yes No Yes No - If Yes, please provide: Yes No - If Yes, what is the health problem, and what kind of medication are you taking? Yes No Yes No Yes No                                                                                                                                                                                                                                                         involve repetitions to the area for which the claim was filed?                         / / / / / / / / / / / / / / Dept. of Labor & Industries ClaimsREPETITIVE TRAUMA PO Box 44291 Olympia WA 98504-4291 QUESTIONNAIRE Claimant's Name Claim Number: Injury Date 1. Condition for which claim was filed 3. While employed, did your symptoms interfere with your work? If Yes, How? 2. When did you first notice you had a problem with your condition? 4. When were you first told by a doctor that your condition was 5. Did you have any diagnostic caused by your job? studies? 6. Name & address of doctor who told you that your condition is occupational: City State ZIP + 4 7. Have you been examined by any other doctors for condition? Name and address of doctor Exam Date HEALTH HISTORY 8. Do you have a health problem for which you must take medication and/or have treatment for on a regular basis? 9. Name of doctor prescribing your medication: Address City State ZIP + 4 10. Have you had any injury to the same area for If Yes, please describe the injury: which this claim was filed? 11. Have you had any illness that affected the same If Yes, please describe the illness: area for which this claim was filed? FAMILY HISTORY 13. Name of your family's physician Address City State ZIP + 4 NON-WORK EXPOSURE 14. Do you have any hobbies or non-work activities which If Yes, please describe: 15. Please list any other hobbies or activities you participate in: F241-016-000 (PDF) repetitive trauma questionnaire 10-00