Form Dfc-F5-Dwc-25 - Florida Workers' Compensation Uniform Medical Treatment/ Status Reporting Form Page 2
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2Florida Workers' Compensation Uniform Medical Treatment/Status Reporting Form - PAGE 2
D/A:
Patient Name:
Soc.Sec.#:
Visit/Review Date:
SECTION IV
FUNCTIONAL LIMITATIONS AND RESTRICTIONS
Assignment of limitations or restrictions must be based upon the injured employee's specific clinical
dysfunction or status related to the work injury. However, the presence of objective relevant medical findings
does not necessarily equate to an automatic limitation or restriction in function.
21
_________________.
No functional limitations identified or restrictions prescribed as of the following date:
22.
The injured workers' functional limitations and restrictions, identified in detail below, are of such severity that he/she
cannot perform activities, even at a sedentary level (e.g. hospitalization, cognitive impairment, infection, contagion),
as of the following date:
___________________.
Use additional sheet if needed.
23.
The injured worker may return to activities so long as he/she adheres to the functional limitations and restrictions
identified below. Identify ONLY those functional activities that have specific limitations and restrictions for this
patient. Identify joint and/or body part __________________________________.
Use additional sheet if needed.
Functional Activity
Load
Frequency & Duration
ROM/ Position & Other Parameters
Bend
Carry
Climb
Grasp
Kneel
Lift-floor > waist
Lift-waist>overhead
Pull
Push
Reach-overhead
Sit
Squat
Stand
Twist
Walk
_
Other
COMMENTS:
Other choices; Skin Contact/ Exposure; Sensory; Hand Dexterity; Cognitive; Crawl; Vision; Drive/Operate Heavy Equipment;
Environmental Conditions: heat, cold, working at heights, vibration; Auditory; Specific Job Task(s); etc.
NOTE: Any functional limitations or restrictions assigned above apply to both on and off the job activities, and are in
effect until the next scheduled appointment unless otherwise noted or modified prior to the appointment date.
Specify those functional limitations and restrictions, in Item 23, which are permanent if MMI / PIR have been assigned in Item 24.
SECTION V
MAXIMUM MEDICAL IMPROVEMENT / PERMANENT IMPAIRMENT RATING
24. Patient has achieved maximum medical improvement?
b) NO
c) Anticipated MMI date:
a) YES, Date:
e)
Yes
f)
No
d) Anticipated MMI date cannot be determined at this time.
Future Medical Care Anticipated:
Comments:
__________________________________________________________________________________
_____
25.
% Permanent Impairment Rating (body as a whole)
Body part/system:
_____________________________
26.
Guide used for calculation of Permanent Impairment Rating (based on date of accident - see instructions):
a) 1996 FL Uniform PIR Schedule
b) Other, specify
______________________________________________
27.
Is a residual clinical dysfunction or residual functional loss anticipated for the work-related injury?
a) YES
b) NO
c) Undetermined at this time.
SECTION VI
FOLLOW-UP
Next Scheduled Appointment Date & Time:
28.
________________________________
SECTION VII
ATTESTATION STATEMENT
“As the Physician, I hereby attest that all responses herein have been made, in accordance with the instructions as part of this form, to a
reasonable degree of medical certainty based on objective relevant medical findings, are consistent with my medical documentation
regarding this patient, and have been shared with the patient."
"I certify to any MMI / PIR information provided in this form.”
Physician Group:
Date:
PARAMOUNT URGENT CARE
Physician Signature:
Physician DOH License #:
Physician Name:
Physician Specialty:
EMERGENCY MEDICINE
(print name)
If any direct billable services for this visit were rendered by a provider other than a physician, please complete sections below:
“I hereby attest that all responses herein relating to services I rendered have been made, in accordance with the instructions as part of this
form, to a reasonable degree of medical certainty based on objective relevant medical findings, are consistent with my medical
documentation regarding this patient, and have been shared with the patient."
Provider Signature:
Provider DOH License #:
Provider Name:
Date:
(print name)
Form DFS-F5-DWC-25 (revised 2/14/2006)
Page 2 of 2
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