Physicians Report {2118}

PHYSICIANS REPORT State Form 2118 (R4 / 8-11) INDIANA WORKER'S COMPENSATION BOARD 402 West Washington Street, Room W196 Indianapolis, IN 46204-2753 Telephone: (317) 232-3808 * This agency is requesting disclosure of your Social Security number in order to pursue its statutory responsibilities. Disclosure is voluntary and you will not be penalized for refusal. INSTRUCTIONS: Page 1 of this form is for the examination; page 2 is for Permanent Partial Impairment (PPI). PATIENT INFORMATION Social Security number * Name of injured employee Age Sex Male Address (number and street, city, state, and ZIP code) Name of employer Address (number and street, city, state, and ZIP code) Female Date of this report (month, day, year) ACCIDENT INFORMATION Date of injury (month, day, year) Briefly describe accident / exposure as reported by worker Time of injury / illness / exposure AM PM PHYSICIANS FINDINGS - Please attach causation. State objective findings of injury / illness / exposure Ability to work Unable to work beginning ______ until ______. Able to work with restrictions beginning ______ until ______. Able to work full duty effective ______. Is this the only cause of patient's condition? (If No, state contributing causes) Yes No In your opinion, are the workers current symptoms a result of the injury described above? If no, did the injury aggravate, exacerbate, or accelerate a pre-existing condition? Yes Yes No No Yes No Has normal recovery been delayed for any reason? (If Yes, please explain) Medical status If MMI, date achieved (month, day, year) Maximum Medical Improvement (MMI) If disabled, type: Disabled Totally and permanent ATTENDING PHYSICIAN TREATMENT Partial but temporary Totally but temporary Date of your first treatment (month, day, year) Describe treatment given or ordered by you Who engaged your services? Was patient treated by a previous physician? (If Yes, by whom, give name) Date treated (month, day, year) Date of admission (month, day, year) Date of discharge (month, day, year) Yes Yes Yes No Name of hospital Was patient hospitalized? No No Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Is further treatment needed? (If Yes, please explain) (Check one) Patient (Check one) was was will be will be able to resume regular work on ___________________________ (month, day, year). able to resume light duty work on _________________________ (month, day, year). Please explain any restrictions below. Patient If there is permanent impairment as a result of this injury / illness / exposure, please give body part affected, degree of impairment and other pertinent information. (If there is an amputation to the hand or the foot, please indicate the point of amputation on one of the diagrams below.) Thumb Finger 1 Finger 2 Finger 3 Finger 4 ______% ______% ______% ______% ______% Toe, Great Toe 2 Toe 3 Toe 4 Toe 5 ______% ______% ______% ______% ______% Hand below elbow Arm above elbow Foot below knee Leg below knee Spine ______% ______% ______% ______% ______% Loss of vision to <1/10 normal ______% Loss of eye ______% Hearing, left or right ______% Hearing, both ears ______% Testicle loss, one ______% Testicle loss, both ______% To calculate the PPI amount, multiply the degree value by the percentage of loss. Multiply the result by the appropriate dollar amount for the date of injury. If an amputation, double the value. Remarks: (Use this section for an independent medical examination report or give any information of value not included above i.e. history, prognosis, or work restrictions of the patient.) Is this report submitted as an independent medical examination? Yes Signature of physician Printed name of physician No Is further treatment necessary? (If necessary, please explain response in the remarks section above. Supplemental reports may be submitted with this form.) Yes No Date (month, day, year) Telephone number ( Address of physician (number and street, city, state, and ZIP code) ) PPI rating provided according to ____________ Ed. AMA guidelines. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com