Short-Term Disability Questionnaire

The questions below are designed to assist your physician in filling out your FMLA form. When answering these qeustions it is helpful for you to have your dates of treatment and diagnosis which can be obtained from your office or hospital discharge paperwork. Please answer these questions as completely and carefully as possible.

Patient Information

First Name Middle Name Last Name *

Policy Number (if applicable)

Area code *

Phone number *

Birth Date (MM/DD/YYYY) *

Employer Name *

Gender *

M

F

Date symptoms first appeared * +

Birth Date of youngest child if applicable (MM/DD/YYYY)

Address *

City *

State *

ZIP *

Is your disability work related? *

Yes

No

Have you filed a Worker's Compensation Claim? *

Yes

No

Last date at work before disability * +

Date you returned or expect to return to work (estimate if you are unsure) * +

Cause of Disability: *

Accident

Illness

Pregnancy

If accident or illness please explain (include dates and locations if applicable) *

Have you done any work activity or self-employment since your disability? *

None

Some

Describe all work activity or self-employment you have done since your disability *

What diagnosis have been given? * 🛈

If you know your ICD-9 code please enter it here 🛈

What symptoms do you have? *

Estimate your height *

Estimate your weight *

What was your most recent blood pressure

Expected date of delivery * +

Actual date of delivery * +

Was your delivery vaginal or C-section *

Vaginal

C-Section

Date your doctor recommended that you stop working * +

Date your symptoms first occurred * +

Have you ever had these same or a similar condition? *

Yes

No

When was the last time you experienced these same symptoms before this episode (MM/DD/YYYY) *

Date of first visit to your doctor for this problem * +

Date of most recent visit to your doctor for this problem * +

What do you expect the frequency of subsequent visits to be *

Weekly

Monthly

Other Other

What treatment have you received *

Which statement most accurately describes the expected length of your treatment? *

Treatment will take a few days

Treatment will take a few weeks

Treatment will take a few months

The duration of treatment is unknown

Were you hospitalized for this condition? *

No

Yes

If hospitalized, date of admission. +

If hospitalized, date of discharge +

Did you have surgery *

Yes

No

Date of surgery * +

What type of surgery did you have? *

Did you have any surgery or post-surgery complications? *

Yes

No

What complication did you have *

What physical or mental limitations and restrictions do you currently have? *

Which of the following applies to your recovery *

Do you know when these limitations or restrictions will end? *

Yes

No

Date you expect limitations or restrictions to end * +

If you do not know when the limitations will end, in how many weeks will you be seen by your doctor for a follow-up exam? *

First and Last Name of Physician *

Credential

Specialty *

Phone number *

Fax Number

Physician's Address *

Physician's City *

Physician's State *

Physician's Zip code *

By clicking the box I certify that I have read and agree to the HIPAA compliance statement *

I Agree

By clicking here I certify that the answers I provided to the above questions are complete and true to the best of my knowledge and belief. *

I agree