Department of Industrial Relations, Industrial Medical Council, PO Box 8888, San Francisco, CA 94128- (650) 737-2700
State of
Qualified or Agreed Medical Evaluator's Findings Summary Form
California
1. Employee Name (First, Middle, Last)
2. Social Sec No.(Optional)
3. Date of Injury (Mo/ Dy/Yr)
Employee
4. Street Address
City
Zip
5. Telephone
Claims
6. Name:
Administrator/
Employer
7. Street Address
City
Zip
8. Telephone
Exam
9. Date of Appointment Call
1 0. Date of Initial Examination
11. Date of Referral for Medical Testing/Consultation
Referral
Schedule
12. Date AME/QME's Report Served on all Parties
13. The following medical issues will be used to determine the patient's eligibility for workers' compensation.
Disputed
Check the appropriate box and reference the corresponding page(s) or section of the med-legal report for details.
Medical
Issues
Report page(s)
And Conclusion
or section
Pending or
Yes
No
Info. Not Sent
a. Is there permanent disability?
b. Is the medical condition stable and not likely
to improve with active medical or surgical treatment
(i.e., is the condition permanent and stationary)?
c. Did work cause or contribute to the injury or illness?
d. If permanent disability exists, is
apportionment warranted?
e. Is there a need for current or future medical care?
f. Can this employee now return to his/her usual job?
Yes
No
If yes:
i. Without restrictions
Yes
No,
If YES, Date:
ii. With restrictions
Yes
No,
If YES, Date:
If restricted work is recommended, reference page(s)/section in report for details:
Basis for
Check box and refer to page(s) or section in report.
Report page(s)
Pending or
Conclusions
or section
Yes
No Info. Not Sent
14. Are there subjective complaints?
15. Are there any abnormal physical or psychological
examination findings?
16. Are there any relevant diagnostic test results (x-ray/laboratory)?
17. What are the diagnoses? (List)
18. Were treating physician's reports reviewed?
19. Were other physicians consulted?
Yes
No
Date:
QME 20. Signature
21. Name
Specialty
22. Street Address
City
Zip
23. Telephone
Cal. #
IMC Form 111 Rev. 4/14/00
(OVER)