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FORM FOR PATIENTS WITH A WORK RELATED INJURY

THIS FORM WILL BE USED TO PROVIDE YOUR SURGEON WITH A DETAILED RECOUNT OF YOUR INJURY. THIS FORM WILL TAKE APPROXIMATELY 10-15 MINUTES TO COMPLETE, BUT WILL PROVIDE INSIGHTFUL INFORMATION AS TO YOUR NEEDS.

Patient Details

Birthday
Day
Month
Year

Injury Details

Add how the injury occurred

Mechanism of injury (check all that apply):
Did you lose consciousness?
Please mark all areas where you sustained injury:
Specific Injuries diagnosed (if known)

Functional Impact

Current ability to open mouth:
Jaw movement difficulties (check all that apply):
Chewing and eating:
Speech difficulties:
Breathing difficulties:
Vision changes:
Sensation changes:

Pain Assessment

Current pain level (0-10 scale, 0=no pain, 10=worst imaginable):

Pain Character: Check all that apply
Does the pain interfere with sleep?

PAIN MANAGEMENT

Other pain management strategies used

Treatment to Date

Immediate treatment received (check all that apply)
Medical specialists and other health providers involved in your care

Work Status and Impact

Employment status before injury
Physical demands of your job (check all that apply)
Current work status:

Activities of Daily Living

Psychological and Social Impact

How has this injury affected your mood? (check all that apply)
Have you experienced any of the following since the injury:
Are you receiving psychological support?
Impact on Relationships

Past Medical History

ADDITIONAL INFORMATION

This questionnaire will be reviewed by the oral and maxillofacial surgery team prior to your consultation. Please bring any relevant imaging, reports, or documentation from previous treating practitioners to your appointment.

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