This form replaces all other disability forms. No outside forms will be completed by Orthopaedic Associates, Inc.

*Date: (mm-dd-yyyy) *Patient's Name: *Patient's Age: *Address: Address 2: *City: *State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *Zip: *Diagnosis: Work Related: Select Yes No *Accident Date: (mm-dd-yyyy) Date First Consulted: (mm-dd-yyyy) Previous Related Condition: Surgical Procedure: Date of Surgery: (mm-dd-yyyy) Dates of Treatment: Office   Hospital     (mm-dd-yyyy)   (mm-dd-yyyy)   (mm-dd-yyyy)   (mm-dd-yyyy)   (mm-dd-yyyy) *Still Under Doctor's Care: Select Yes No Discharged: Select Yes No Totally Disabled: Select Yes No Totally Disabled Through: (mm-dd-yyyy) Partially Disabled: Select Yes No Partially Disabled Through: (mm-dd-yyyy) Remarks:     __________________________________________ _____________________ Signature Date