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Primary Treating Physicians Permanent And Stationary Report DWC-PR-3 - California
| Primary Treating Physicians Permanent And Stationary Report Form. This is a California form and can be used in General Workers Comp . |
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STATE OF CALIFORNIA Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-3) This form is required to be used for ratings prepared pursuant to the 1997 Permanent Disability Rating Schedule. It is designed to be used by the primary treating physician to report the initial evaluation of permanent disability to the claims administrator. It should be completed if the patient has residual effects from the injury or may require future medical care. In such cases, it should be completed once the patient's condition becomes permanent and stationary. This form should not be used by a Qualified Medical Evaluator (QME) or Agreed Medical Evaluator (AME) to report a medical-legal evaluation. Patient: Last Name ______________________ Middle Initial ____ First Name __________________ Sex___ Date of Birth ________ Address ______________________________________________ City _______________________ State _____ Zip _______ Occupation ___________________________ Social Security No. _____________________ Phone No.__________________ Claims Administrator/Insurer: Name ____________________________________________ Claim No. _____________________ Phone No._____________ Address __________________________________________ City __________________________ State _____ Zip ________ Employer: Name ____________________________________________________________________ Phone No. ___________________ Address _______________________________________ City _________________________ State ___________ Zip ______ You must address each of the issues below. You may substitute or append a narrative report if you require additional space to adequately report on these issues. Date of Injury_____________ Last date _____________ Date of current _______________ Permanent & __________ Date worked Date examination Date Stationary date Date Description of how injury/illness occurred (e.g. Hand caught in punch press; fell from height onto back; exposed 25 years ago to asbestos): Patient's Complaints: STATE OF CALIFORNIA DWC Form PR-3 (Rev. 06-05) 1 American LegalNet, Inc. www.USCourtForms.com Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-3) Relevant Medical History: Objective Findings: Physical Examination: (Describe all relevant findings; include any specific measurements indicating atrophy, range of motion, strength, etc.; include bilateral measurements - injured/uninjured - for upper and lower extremity injuries.) Diagnostic tests results (X-ray/Imaging/Laboratory/etc.) Diagnoses (List each diagnosis; ICD-9 code must be included) 1. ___________________________________________________ 2. ___________________________________________________ 3. ___________________________________________________ 4. ___________________________________________________ ICD-9 ______________________________________ ______________________________________ ______________________________________ ______________________________________ Yes Can this patient now return to his/her usual occupation? No Cannot Determine If not, can the patient perform another line of work? DWC Form PR-3 (Rev. 06-05) 2 American LegalNet, Inc. www.USCourtForms.com STATE OF CALIFORNIA Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-3) Subjective Findings: Provide your professional assessment of the subjective factors of disability, based on your evaluation of the patient's complaints, your examination, and other findings. List specific symptoms (e.g. pain right wrist) and their frequency, severity, and/or precipitating activity using the following definitions: Severity: Minimal pain - an annoyance, causes no handicap in performance. Slight pain - tolerable, causes some handicap in performance of the activity precipitating pain. Moderate pain - tolerable, causes marked handicap in the performance of the activity precipitating pain. Severe pain - precludes performance of the activity precipitating pain. Occasional - occurs roughly one fourth of the time. Intermittent - occurs roughly one half of the time. Frequent - occurs roughly three fourths of the time. Constant - occurs roughly 90 to 100% of time. Frequency: Precipitating activity: Description of precipitating activity gives a sense of how often a pain is felt and thus may be used with or without a frequency modifier. If pain is constant during precipitating activity, then no frequency modifier should be used. For example, a finding of "moderate pain on heavy lifting" connotes that moderate pain is felt whenever heavy lifting occurs. In contrast, "intermittent moderate pain on heavy lifting" implies that moderate pain is only felt half the time when engaged in heavy lifting. Yes Pre-Injury Capacity Are there any activities at home or at work that the patient cannot do as well now as could be done prior to this injury or illness? No Cannot determine If yes, please describe pre-injury capacity and current capacity (e.g. used to regularly lift a 30 lb. child, now can only lift 10 lbs.; could sit for 2 hours, now can only sit for 15 mins.) 1. 2. 3. 4. DWC Form PR-3 (Rev. 06-05) 3 American LegalNet, Inc. www.USCourtForms.com STATE OF CALIFORNIA Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-3) Preclusions/Work Restrictions Yes Are there any activities the patient cannot do? No Cannot determine If yes, please describe all preclusions or restrictions related to work activities (e.g. no lifting more than 10 lbs. above shoulders; must use splint; keyboard only 45 mins. per hour; must have sit/stand workstation; no repeated bending). Include restrictions which may not be relevant to current job but may affect future efforts to find work on the open labor market (e.g. include lifting restriction even if current job requires no lifting; include limits on repetitive hand movements even if current job requires none). 1. 2. 3. 4. 5. 6. Medical Treatment: Describe any continuing medical treatment related to this injury that you believe must be provided to the patient. ("Continuing medical treatment" is defined as occurring or presently planned treatment.) Also, describe any medical treatment the patient may require in the future. ("Future medical treatment" is defined as treatment which is anticipated at some time in the future to cure or relieve the employee from the effects of the injury.) Include medications, surgery, physical medicine services, du
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