SUBSEQUENT INJURY BENEFITS TRUST FUND (ENGLISH)

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

S.S.N

GenderMaleFemale

Working NowYesNo

Interpreter Name

Height

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.

Section (Skin)

Skin

Pruritus - itching - scratching

Date of Onset

Burns

Date of Onset

Scars

Date of Onset

Dermatitis - hives

Date of Onset

Skin grafts

Date of Onset

Discoloration/pigment changes

Date of Onset

Allergy to latex gloves

Date of Onset

Psoriasis - eczema

Date of Onset

Skin cancer

Date of Onset

Other

Date of Onset

Section (Blood)

Blood

Anemia

Date of Onset

Bruising easily

Date of Onset

Spleen disease

Date of Onset

Leukemia

Date of Onset

Blood transfusion

Date of Onset

Red/white blood cell disorder

Date of Onset

Bleeding easily

Date of Onset

Other

Date of Onset

Other

Other conditions not listed

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

Section (Urinary System)

Urinary System

Excessive urination

Date of Onset

Kidney disease/kidney stones

Date of Onset

Unexpected urination

Date of Onset

Bladder disease - infections

Date of Onset

Difficulty urinating

Date of Onset

Blood in the urine

Date of Onset

Prostate disease

Date of Onset

Other

Date of Onset

Section (Sexual Dysfunction)

Sexual Dysfunction

Sexual dysfunction

Date of Onset

Erectile dysfunction - men

Date of Onset

Other

Other conditions not listed

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

Section (Fractures)

Fractures

Upper extremity

Date of Onset

Pelvis

Date of Onset

Lower extremity

Date of Onset

Spine

Date of Onset

Torso - ribs - chest

Date of Onset

Cranium - skull - face

Date of Onset

Other

Date of Onset

Section (Headaches)

Section (Arthritis)

Other

Other conditions not listed

If you selected (Yes) to any of the above conditions, please answer the questions below

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

Doctor-facility-hospital-clinic name

City

Address if known

Information About Your 'Last' Work Injury

Employer Name

Date of work injury

Are you still working for this employer?YesNo

What was the last day you worked at this employment?

Please describe the body parts that were injured 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?YesNo

Please describe the treatment that you are receiving below

Information About Your Health 'Before' Your Last Work Injury

Did you have any conditions, difficulties or health problems before the work injury?YesNo

Please list all your prior conditions, illnesses, limitations, difficulties or health concerns below

Any prior problems with your upper or lower extremities, eyes, ears, kidneys or Jaw?YesNo

Bilateral Conditions

Right hip
Left hip
Right groin
Left groin
Right thigh
Left thigh
Right knee
Left knee
Right calf - shin
Left calf - shin
Right ankle
Left ankle
Right foot - toes
Left foot - toes
Right kidney
Left kidney

Right shoulder
Left shoulder
Right arm
Left arm
Right elbow
Left elbow
Right forearm
Left forearm
Right wrist
Left wrist
Right hand - fingers
Left hand - fingers
Right eye
Left eye
Right TMJ - Jaw
Left TMJ - Jaw

Please mention the condition along with the date of onset

Bilateral Conditions

Date of Onset

If you had any other condition, please mention it below along with the Date of Onset.

Bilateral Conditions

Date of Onset

Current Home Care

Please describe current home care below

Current Aids

Please describe all aids used currently

How often is it being used?

Current Medication

Source of medicationOver-the-counterPrescriptionBoth

Please list all medications taken currently

How often is the medication taken?

Surgical History

Have you had any surgeries?YesNo surgeries doneOther

Please list all surgeries

Date surgery was performed?

Other

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 on the image below)

Symptoms or abbreviations mentioned above

Symptom Diagram

InterpreterYesNo

Interpreter Name