West Virginia > Workers Comp
Physical Medicine Follow Up Report BI-231 - West Virginia
| Physical Medicine Follow Up Report Form. This is a West Virginia form and can be used in Workers Comp . |
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BI-231 01/06 Physical Medicine Follow-up Report Claimant Name: Claim Number: Claimant SSN: Date of Injury: Physician's Name and Address: 2. Please complete the chart below. Modality Active ROM Passive ROM Strengthening Exercises Aquatic Therapy Massage Ultrasound COMPLETE THE FORM IN BLACK INK. Return completed form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 Date: Vendor Number: Physician Number: 1. Date of this evaluation: Frequency Duration Improved Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No Modality E- Stim Chiropractic Manipulations Osteopathic Manipulations Heat Ice lontophoresis Phonophoresis Traction Other Frequency Duration Improved Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No TENS Other 3. Active ROM "*You may obtain this Information from the physician or therapist providing the treatment** Body Part Flexion Extension Adduction IR ER Other Other 4. Passive ROM **You may obtain this information from the physician or therapist providing the treatment"* Body Part Flexion Extension Adduction IR ER Other Other 5. Manual Muscle Testing **You may obtain this information from the physician or therapist providing the treatment** Body Part Results 11. Grip Strength RT LFT kg kg 12. Asymmetrical Reflexes RUE LUE RLE LLE 13. What are your subjective and objective findings? Pain Edema Limited AROM Limited PROM Tenderness Other (explain) Effusion I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware that the law, specifically ยง61-3-24g, provides for severe penalties if I knowingly certify a false report or statement, withhold material fact or statement or knowingly aid or abet anyone attempting to secure benefits to which he or she is not entitled. In signing this form, I acknowledge my contractual obligations to BrickStreet Insurance and agree to release any office notes and test results immediately to BrickStreet Insurance. PHYSICIAN SIGNATURE: DATE: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332 American LegalNet, Inc. www.USCourtForms.com
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