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WRONGFUL TERMINATION / WORKERS COMPENSATION INTAKE FORM

Prior to pursuing your wrongful termination claim, it is imperative to be aware that terminated employees may also have workers’ compensation claims that often result in higher settlements compared to wrongful termination claims. (Though termination is not a requirement of having a workers compensation claim) To ascertain whether you qualify for a cumulative trauma claim, kindly answer the following questions:

Have you been employed for a year or more?

*

Have you been employed for a year or more?

A

Yes

B

No

Have you experienced any pain in any part of your body while preforming your job duties over the course of the last year?

*

Have you experienced any pain in any part of your body while preforming your job duties over the course of the last year?

A

Yes

B

No

What parts of your body have you experienced pain in during the course of your work over the last year?

What parts of your body have you experienced pain in during the course of your work over the last year?

Head

Neck

Radiating pain from the neck to the left arm

Radiating pain from the neck to the right arm

Shoulder (Left)

Shoulder (Right)

Elbow (Left)

Elbow (Right)

Wrist (Left)

Wrist (Right)

Hand (Left)

Hand (Right)

Back

Radiating pain from back to left leg

Radiating pain from back to right leg

Hip (Left)

Hip (Right)

Knee (Left)

Knee (Right)

Ankle (Left)

Ankle (Right)

Foot (Left)

Foot (Right)

Have you had a diagnosis or worsening to any of the following conditions over the last year?

*

Have you had a diagnosis or worsening to any of the following conditions over the last year?

Diabetes

High blood pressure

Gerd

Sleep apnea

Please provide a detailed description of your work-related injury, including the specific circumstances that led to its occurrence and the nature of the injuries sustained.