FORM 105 ADOPTED: January 1, 1997
KENTUCKY DEPARTMENT OF WORKERS CLAIMS PLAINTIFF'S CHRONOLOGICAL MEDICAL HISTORY Include all injuries and major illnesses to the date of filing of the claim (Begin with most recent treatment) Name & Address of Physician or Hospital 1. Date Treatment Received Nature of Injury or Disease and Part of body affected? Still under a doctor's care?
I hereby certify that the above information is true and correct to the best of my knowledge and belief. ___________________________________________ Plaintiff's Signature _________________________________ Date