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White Finger Intake Form

Please fill out the information requested below and a representative will contact you.

Name:


Address (City, State, Zip)


Email


Home Phone


Work Phone


Name and Address of Most Recent Employer


Job Title


Date Hire


Date Retire


Do your hands go white?
Yes
No

Do your hands, wrists or forearms ache?
Yes
No

Have you got problems with your hands in the cold?
Yes
No

Do you have problems with your hands due to using vibrating power tools?
Yes
No

Do your hands tingle and go numb?
Yes
No

What makes your hands tingle and go numb?


Have you been diagnosed by a doctor with any hand problems?
Yes
No

If yes, list name and address of doctor and date of diagnosis.


Are you covered by health insurance?
Yes
No

Do you or have you used the following tools?
Fein Knife or Cut-Out Tool
Percussive tools e.g. riveting, caulking, fettling and swaging
Grinders including pedestal and hand-held grinders
Pneumatic drills and hammers, including percussive and rotary hammers
Chain saws and other garden machinery

Other Tools


Have you ever worked in the windshield replacement industry?
Yes
No

Date of workers' compensation or disability claim filed for hands




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