Duties Performed Under Duress at Work an

top of page

Heal 360 Rehab

About
Services
StemWave Therapy
Forms
New Patient Form
Medical History
consent to release
Acknowledgement of receipt of HIPPA Notice of Privacy Practices
Request for Confidential Communication or your Protected Health Information
Financial Responsibility Agreement
Contractual Lien
Informed Consent to Chiropractic Treatment
Duties Performed Under Duress at Work and Home
Accident Questionnaire
Post-Concussion Symptoms Questionnaire
New Patient Form
Medical History
consent to release
Acknowledgement of receipt of HIPPA Notice of Privacy Practices
Request for Confidential Communication or your Protected Health Information
Financial Responsibility Agreement
Contractual Lien
Informed Consent to Chiropractic Treatment
Duties Performed Under Duress at Work and Home
Accident Questionnaire
Post-Concussion Symptoms Questionnaire

Schedule An Appointment

Heal 360 Rehab

Duties Performed Under Duress at Work and Home

Duties Performed Under Duress at Home and Work

Is this an Initial assessment or an Update?

Initial

Update

Please check all that apply to your WORK/EMPLOYMENT because of the accident

I go to work but work in pain

I limit my work activities

Bending at work hurts

Stooping at work hurts

Sitting at work hurts

Using the computer at work hurts

Pushing at work hurts

Kneeling at work hurts

I have lost status in my company

I have lost job security

I didn't get a promotion

I don't enjoy work as much as before

I doze off at work

I take unpaid time off work to go to Dr.

I daydream at work more than before

I feel tired at work

I work in pain because I have bills to pay

I can't take time off because I would lose my job

I keep working so I don't lose status at company

My business would fail if I took time off

I believe in working even when I'm in pain

I feel obligated to work even though I'm in pain

My business would lose money if I took time off

My work is not as good as it was before accident

My boss reprimanded me for poor performance

I got a different job within the same company

I got a different job in another company

I make less money than before the accident

I cannot do the same work/job as before accident

I can't concentrate as well at work

I take paid time off to go to Dr.

I make mistakes at work I didn't use to

I hide my poor work performance from my boss

Please check all that apply to your HOME/DOMESTIC because of the accident

My house is not as clean now

My yard is not as neat now

My garden is not as productive now

I do yard work, but do it in pain

I cannot do my normal yard work

I do house work, but do it in pain

I cannot do my normal house work

Doing laundry hurts me

I cannot do laundry now

Washing dishes hurts me

I cannot vacuum now

Cooking hurts me

I cannot cook now

Washing the car hurts me

I cannot wash my car

I cannot take time off because I care for children

I had to hire a paid housekeeper

I asked someone for unpaid housekeeping help

I had to hire a paid gardener

I asked someone for unpaid yard work help

Mowing the lawn hurts me

I cannot mow the lawn

Taking out the trash hurts me

I cannot take out the trash

I do not enjoy my gardening/yardwork like I used to

I do not enjoy my housework like I used to

Gardening hurts me

I cannot do my gardening at all since the accident

Others living with me do my share of the work now

Others living with me do my share of the yard now

Others living with me do my share of the gardening

Number of children (if applicable)

Ages of children (if applicable)

Please do not submit any Protected Health Information (PHI).

Heal 360 Rehab

3939 W Green Oaks Blvd Ste 100, Arlington, TX 76016

(469) 573-4223

bottom of page