Tennessee > Workers Compensation
Standard Form Medical Report For Industrial Injuries C-32 - Tennessee
| Standard Form Medical Report For Industrial Injuries Form. This is a Tennessee form and can be used in Workers Compensation . |
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TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers Compensation nd 710 James Robertson Parkway, 2 Floor Nashville, Tennessee 37243-0661 STANDARD FORM MEDICAL REPORT FOR INDUSTRIAL INJURIES ____________________________________________________________________________________________ A. PATIENT INFORMATION (Please type or neatly print all responses) ____________________________________________________________________________________________ 1. Name and Address ____________________________________________________________________________________________ 2. Social Security Number 3. Date of Exam(s) 4. Date of Birth 5. Treating Physician [ ] Evaluating Physician [ ] - Upon Whose Request: __________________________________________________________________ - Date of Request: ______________________________________________________________________ ____________________________________________________________________________________________ B. PATIENT HISTORY ____________________________________________________________________________________________ Include pertinent history of injury along with current treatment, hospitalization(s) and period(s) claimant unable towork. ____________________________________________________________________________________________ C. PHYSICAL EXAMINATION ____________________________________________________________________________________________ Include chief complaints and state all findings relative to the injury. Form C-32LB-0369 (rev. 7-1-99) -1- <<<<<<<<<********>>>>>>>>>>>>> 2____________________________________________________________________________________________ D SUMMARY OF DIAGNOSTIC TESTING ____________________________________________________________________________________________ In the space below, check the applicable blocks next to any test results which you reviewed and relied upon to base yourmedical assessments or conclusions. Be sure to show the date of each test, and summarize results. Attach copy(s) ofreports, if available. DATE SUMMARY OF RESULTS ______________________________________________________________________________________________ [ ] X-RAY ______________________________________________________________________________________________ []E MG ______________________________________________________________________________________________ [ ] CT SCAN ______________________________________________________________________________________________ [ ] MYELOGRAM ______________________________________________________________________________________________ []M RI ______________________________________________________________________________________________ [ ] OTHERS ______________________________________________________________________________________________ E. SURGICAL PROCEDURES ______________________________________________________________________________________________ Please specify (Attach Operative Note) Form C-32LB-0369 (rev. 7-1-99) -2- <<<<<<<<<********>>>>>>>>>>>>> 3F. IMPAIRMENT 1. As a result of this injury, did the claimant suffer temporary total disability? Yes___ No ___ If yes, please provide the period(s) of time during which the claimant was temporarily totally disabled. From To From To From To From To 2. Please provide the date on which the claimant was released to return to work. Return to work date: ___________________ 3. Please provide the date on which the claimant reached maximum medical improvement (MMI). Date of MMI: _________________ 4. Using the AMAs Physicians Guide to Evaluation of Permanent Impairment (latest edition available) or the Manual of Orthopedic Surgeons In Evaluating Permanent Physical Impairment, please translate the Claimants condition to a percentage of impairment. _____________________% scheduled member ______________% whole body NOTE: Be sure to include all references to both Chapters 1 and 2 of the Guidelines. If chapter 2 is not used, please specify why it is not appropriate in this evaluation. What tables did you use in arriving at this percentage? Table ______________ Page_______________ Table ______________ Page ______________ Table ______________ Page_______________ Table ______________ Page ______________ Table ______________ Page_______________ Table ______________ Page ______________ NOTE: Please explain specifically how you arrived at the above calculation. 5. If you feel that the AMA Guide or the Orthopedic Manual does not adequately assess the medical impairment of the Claimant, please express an impairment that you think is appropriate for this patient. Please explain how you arrived at this percentage: _____________________% scheduled member ______________% whole body6. Considering the nature of Claimants occupation and medical history along with diagnosis and treatment, does this injury more probably than not arise out of the claimants employment? Yes ___ No ____ Form C-32LB-0369 (rev. 7-1-99) -3- <<<<<<<<<********>>>>>>>>>>>>> 4 ____________________________________________________________________________________ G. FUNCTIONAL CAPACITY ASSESSMENT ____________________________________________________________________________________ LIMITED, BUT RETAINS MAXIMUM CAPACITIES TO: Lift (including upward pulling) and/or CARRY: [ ] 10 lbs. [ ] 15 lbs. [ ] 20 lbs. [ ] 25 lbs [ ] 30 lbs. [ ] 35 lbs. [ ] 40 lbs. [ ] 45 lbs. [ ] 50 lbs. or more FREQUENTLY LIFT and/or CARRY: [ ] 10 lbs. [ ] 15 lbs. [ ] 20 lbs. [ ] 25 lbs [ ] 30 lbs. [ ] 35 lbs. [ ] 40 lbs. [ ] 45 lbs. [ ] 50 lbs. or more OCCASIONALLY LIFT and/or CARRY: [ ] LESS than ABOUT 3 hrs. (If marked limitation, explain) [ ] LESS than 10 lbs. (e.g. files, ledgers, small tools, etc.) STAND and/or WALK A TOTAL OF: [ ] LESS than ABOUT 3 hrs. (If marked limitation, explain) [ ] LESS than ABOUT 6 hrs. (If marked limitation, explain) [ ] ABOUT 6 hrs. (Per 8-hr. day) SIT A TOTAL of: [ ] LESS than ABOUT 3 hrs. (If marked limitation, explain) [ ] LESS than ABOUT 6 hrs. (If marked limitation, explain) [ ] ABOUT 6 hrs. (Per 8-hr. day) PUSH and/or PULL (Including hand/or foot controls): [ ] UNLIMITED [ ] LIMITED (Describe degree of limitation) PHYSICAL FACTORS: Frequently Occasionally Never Unlimited Limited Climbing [ ] [ ] [ ] Reaching [ ] [ ] Balancing [ ] [ ] [ ] Handling [ ] [ ] Stooping [ ] [ ] [ ] Fingering [ ] [ ] Kneeling [ ] [ ] [ ] Feeling [ ] [ ] Crouching [ ] [ ] [ ] Seeing [ ] [ ] Crawling [ ] [ ] [ ] Hearing [ ] [ ] Twisting [ ] [ ] [ ] Speaking [ ] [ ] Describe in what ways the impaired activities are l
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