Workman's Compensation History Form

Workman’s Compensation HISTORY
Time
:
Head/ Body position at the time of impact:
As a result of the accident you were:
Were you wearing a hat or glasses?
Could you move all parts of your body?
Were you able to get out of the car and walk unaided?
Did you get any bleeding cuts?
Did you get any bruises?

Please describe how you felt:

Check ALL symptoms that you have notice since the accident:

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