SIBTF Intake Form | Dial & Associates PC

SIBTF is a little-known benefit in California's workers' comp system. Dial & Associates assists clients who reach out to us and welcome referrals from other law firms seeking our specialized knowledge to help their clients access these vital benefits.

Name

Date of Birth

Complete Address

Phone

Email Address *

Gender

Male Female

Working Now

Yes No

Interpreter Name

Height

Feet

Inches

Weight (in Pounds)

Today's Date

Have you had, or do you have any of these conditions? If yes, please mark the condition and list the date of onset.

Have you had, or do you have these conditions? If yes, please also list the date of onset.

If You Selected Yes to Any Previous Conditions, Please Answer Below

List below the doctors · facilities · hospitals · clinics that treated/evaluated you, with city and address

Information About Your 'Last' Work Injury

Employer Name

Date of Work Injury

WC / EAMS Case Number (ADJ), if known

Is Your Workers' Comp Case Still Open?

Yes No Not sure

Don't know your case number? It can be looked up in the state's EAMS system — leave it blank and we can help locate it.

Are You Still Working For This Employer?

Yes No

Please describe the body parts that were injured/claimed as a result of this work injury

Please List The Permanent Disability Rating As A Result Of This Work Injury, If Known (In %)

Are You Still Getting Medical Care For This Injury?

Yes No

Please Describe The Treatment That You Are Receiving Below

Do You Have Any QME or AME Reports From Your Workers' Comp Case?

Yes No Not sure

If yes, please list the evaluating doctor(s) and report date(s), and note whether you have copies

Information About Your Health 'Before' Your Last Work Injury

Did You Have Any Conditions, Difficulties Or Health Problems Before The Work Injury?

Yes No

Any Prior Problems With Your Upper Or Lower Extremities, Eyes, Ears, Kidneys Or Jaw?

Yes No

Please mention the condition along with the date of onset

Current Home Care

Please describe current home care below

Current Aids

Please describe all aids used currently and how often they are being used

Current Medication

Source Of Medication

Over-the-counter Prescription Both

Please list all medications you are currently taking and how often they are used

Have You Had Any Surgeries?

Yes No surgeries done Other

Please list all surgeries and the date on which they were performed

Note the areas on your body where you have the symptoms.

P = Pain | N = Numbness/Tingling | T = Tenderness | B = Burning | R = Radiating

Location on body (list number shown in the diagram below) and symptom abbreviations mentioned above

Symptom Diagram

Front View

Back View

Zone Reference · Front

1 Head 2 Neck 3 R Shoulder 4 L Shoulder 5 R Chest 6 L Chest 7 R Upper Arm 8 L Upper Arm 9 R Forearm 10 L Forearm 11 R Hand 12 L Hand 13 Abdomen 14 R Hip 15 L Hip 16 R Thigh 17 L Thigh 18 R Knee 19 L Knee 20 R Shin 21 L Shin 22 R Foot 23 L Foot

Zone Reference · Back

24 Back of Head 25 Back of Neck 26 R Shoulder (back) 27 L Shoulder (back) 28 Upper R Back 29 Upper L Back 30 Mid R Back 31 Mid L Back 32 Lower R Back 33 Lower L Back 34 R Upper Arm (back) 35 L Upper Arm (back) 36 R Forearm (back) 37 L Forearm (back) 38 R Buttock 39 L Buttock 40 R Thigh (back) 41 L Thigh (back) 42 R Knee (back) 43 L Knee (back) 44 R Calf 45 L Calf 46 R Heel 47 L Heel

Interpreter

Yes No