For Referrals: Build Your Assignment Letter Online

Upon Submission You Will Be Emailed A Copy For Your Records
(* Required Fields)

CONTACT INFO

*Your Name:	*Your Company:

Your Email Address:	Company Address:

	*Company Phone:

DO YOU WANT THE REPORT SENT VIA:
(Please enter appropriate info or "N/A")

*US Mail (enter address):	*Fax (enter number):

*Email (enter email address):	Other (enter instructions):

EXAMINATION INFORMATION

*Examinee Name:	*Examinee Claim Number:

	File Number:

*Employer Name:	*Enter the Date of Injury or please note if due to Occupational Disease:

*Part of body injured or condition:	Mechanism of Injury:

Initial Diagnosis:	Current Complaint(s):

*Purpose of Examination:
Rating
Treatment recommendations
Second Opinion for:
Causality
Other (Please specify):

Questions (Please tick the box for the questions / sections you wish included)

Diagnosis(es) and the(ir) relationship to the injury / condition on a more-probable-than-not basis.

Is further treatment recommended?

If further treatment is recommended, is it curative or palliative?

If further treatment is recommended, please specify:   a) type of treatment   b) duration of treatment  c) expected outcome of treatment.

If no treatment is recommended, is the injury or condition fixed and stable [at maximum medical improvement]?

If the injury or condition is fixed and stable, please rate based on the:
   AMA Guides to the Evaluation of Permanent Impairment, Edition
  State of Washington Category Rating System
  Jones Act
  Federal Employers Liability Act
  Death on the High Seas Act
   Longshore and Harbor Workers Compensation Act
  Other (please specify)

Please specify the objective findings upon which your treatment recommendation(s) OR rating is based.

WORK ABILITY

Is the examinee able to return to the job of injury?

If there are restrictions in returning to the job of injury, please specify the restrictions and indicate if they are temporary or permanent.

Is the examinee able to be gainfully employed on a reasonably continuous basis?

If there are restrictions to gainful employment, please specify the restrictions and indicate if they are temporary or permanent.

I will submit job analyses.

Please complete a Physical Capacities Evaluation form.

Please complete an Occupational Disease Work History.

Other:

Other:

PSYCHIATRIC EVALUATIONS

Is a psychiatric disorder present?

If yes:
Provide a diagnosis made in conformity with the current edition of the Diagnostic and Statistical Manual of Mental Disorders.

Please indicate whether the condition(s) were caused or aggravated by the industrial injury or occupational disease.

If the condition(s) were a temporary aggravation, has/have it/they now returned to pre-injury status?

Include your responses to Axes I through V.

Did you note non-anatomic pain behavior, symptom magnification, or somatization in the medical history or examination? If so, please explain, in detail.

Is further treatment necessary for the psychiatric disorder?

If yes, a) Please indicate the type of treatment. b) Expected frequency and duration of treatment. c) Expected outcome of such treatment.

If no treatment is recommended, is the psychiatric condition fixed and stable [at maximum medical improvement]?

If the psychiatric condition is fixed and stable, please rate using the:
rating system.

Please specify the objective findings upon which your treatment recommendation OR rating is based.

Work Ability Based On Psychiatric Condition

Describe any barriers that the psychiatric condition will pose to returning the examinee to work.

Is the examinee able to return to the job of injury?

If there are restrictions in returning to the job of injury, please specify the restrictions and indicate if they are temporary or permanent.

Is the examinee able to be gainfully employed on a reasonably continuous basis?

If there are restrictions to gainful employment, please specify the restrictions and indicate if they are temporary or permanent.

I will submit job analyses.

Other:

Other:

Seattle Small Business Website Design by Aldebaran Website Design
Site Last Updated: