C131 FOOT AND ANKLE QUESTIONNAIRE CLAIMS DIVISION SFN 51817 ( 11 /20 1 8 ) 1600 E C entury A ve , S te 1 PO Box 5585 Bismarck ND 58506 - 5585 Telephone 800 - 777 - 5033 Toll Free Fax 888 - 786 - 8695 TTY ( hearing impaired ) 800 - 366 - 6888 Fraud and Safety Hotline 800 - 243 - 3331 www.w orkforce s afety.com SECTION 1 Claim number (First name) (Last name) Body part(s) SECTION 2 Current condition When did you first notice problems with your foot and/or ankle? What were you doing when the problems occurred ? Describe your current job duties . How much time per day is spent performing the described duties? How long have you worked for your current employer ? How long have you done this type of work? If you changed positions within the company, describe the physical activities of the prior position(s). When did you become aware your condition was related to your work? SECTION 3 Prior condition Have you ever injured your foot and/or ankle before ? Yes No If yes, how did the injury occur ? If yes, when did the injury occur? If yes, where did you treat? Have you ever treated previous symptoms on your own (Example: using a brace, exercise, orthotics, or over - the - counter medication)? Yes No If yes, describe American LegalNet, Inc. www.FormsWorkFlow.com SFN 51817 ( 11 /201 8 ) Claim number W (First name) (Last name) C131 Have you been treated by a n orthopedist or podiatrist (foot doctor)? Yes No If yes, list the name(s) and a ddresses of medical provider(s) who treated you for these conditions. Have you had x - rays, MR I or CT scans of your feet or ankles ? Yes No If yes, list the date, where the imaging was done, and the results . Do you have any congenital foot deformity since birth (Example: flat feet, high arches, etc) ? Yes No If yes, describe . Have you been dia gnosed with diabetes or arthritis? Yes No If yes, describe . Have yo u had recent trauma to your feet or ankles ? Yes No If yes, describe . Do you participate in sports or hobbies outside of work ? Yes No If yes, list the sport or hobby and describe how often you do them . Do you walk or run as part of an exercise program ? Yes No How much time per day is spent walking or running ? How much time per week is spent walking or running? How far do you walk or run ? List exercise besides walking or running. Have you been told your recent symptoms are related to your work duties ? Yes No If yes, list the name(s) and addresses of medical provider(s) who told you your recent symptoms are related to your work duties. List the date the medical provider(s) told you your recent symptoms are related to your work duties. American LegalNet, Inc. www.FormsWorkFlow.com 3 of 3 SFN 51817 ( 11 /201 8 ) Claim number W (First name) (Last name) C131 What type of footwear do you normally wear at work? What type of footwear do you normally wear outside of work? Women: Are you post - menopausal ? Yes No SECTION 3 Release of information/fraud warning/signature Release of information I understand and agree t hat North Dakota law determines all my rights and obligations to and from WSI. I authorize any medical r military agency, any gover nment benefit agency including the Social Security Administration, and any educational agency or institution to release to WSI, its agents and attorneys, any and all information or records, including all prior records as well as those pe rtaining to mental health, alcohol, or drug abuse, and HIV/AIDS/AIDS - related illness. I authorize healthcare providers to respond to WSI regarding my injury, including request for conclusions and opinions not otherwise contained within existing medical records. In additio n, 21 Sec. 1232g. This authorization continues while I have any claim open or pending before WSI. WSI is exempt from HIPAA regulatio ns. I authorize WSI to release any information or records about my claim to third parties or their insurers for the purpose of re solving claims against third parties. I authorize the release of any medical information related to my claim to my employer. Fraud warning Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the receipt of income or an increase in income from employment, in connection with any claim or applicatio benefits will forfeit any future benefits and may be guilty of a felony which is punishable by imprisonment, substantial fine s, or both. These criminal penalties are applicable to all persons dealing with WSI, including injured workers, employers, medical providers, and attorneys. Signature By signing this form, I acknowledge that I have read and understand the release of i nformation and f raud w arning. I understand that falsifying this claim or making a false statement regarding this claim may be a felony, punishable by substantial fines and imprisonment. I authorize the release of information and agree that statements in this form are true and a ccurate. Date American LegalNet, Inc. www.FormsWorkFlow.com