Form C-4.2 - Doctor'S Progress Report - 2015 Page 2
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1
2
3Patient's Name:
Date of injury/onset of illness:______/______/______
Last
First
MI
2. List any changes revealed by your most recent examination in the following: area of injury, type/nature of injury, patient's subjective complaints
or your objective findings: _____________________________________________________________________________________________
3. List additional body parts affected by this injury, if any: ______________________________________________________________________
4. Based on your most recent examination, list changes to the original treatment plan, prescription medications or assistive devices, if any:
5. Based on this examination, does the patient need diagnostic tests or referrals?
Yes
No
If yes, check all that apply:
Tests:
Referrals:
EMG/NCS
CT Scan
Chiropractor
Internist/Family Physician
MRI (specify):
Occupational Therapist
Labs (specify):
Physical Therapist
X-rays (specify):
Specialist in:
Other (specify):
Other (specify):
Important: Form C-4 AUTH should be used to request any special medical service over $1000 or for those services requiring pre-authorization pursuant to the Medical
Treatment Guidelines for the back, neck, knee and shoulder.
6. Describe treatment rendered today:
3-4 wks
7. When is patient's next follow-up visit?
Within a week
5-6 wks
7-8 wks
as needed
1-2 wks
____ months
E. Doctor's Opinion (based on this examination)
1. In your opinion, was the incident that the patient described the competent medical cause of this injury/illness?
Yes
No
2. Are the patient's complaints consistent with his/her history of the injury/illness?
Yes
No
3. Is the patient's history of the injury/illness consistent with your objective findings?
Yes
No
N/A (no findings at this time)
4. What is the percentage (0-100%) of temporary impairment? ______________%
5. Describe findings and relevant diagnostic test results:_______________________________________________________________________
_________________________________________________________________________________________________________________
F. Return to Work
1. Is patient working now?
If yes, are there work restrictions?
If yes, describe the work restrictions:
Yes
No
Yes
No
How long will the work restrictions apply?
1-2 days
3-7 days
8-14 days
15+ days
Unknown at this time
2. Can patient return to work? (check only one)
a.
The patient cannot return to work because (explain):
b.
The patient can return to work without limitations on: _______/_______/_______
The patient can return to work with the following limitations (check all that apply) on: _______/_______/_______
c.
Bending/twisting
Lifting
Sitting
Climbing stairs/ladders
Operating heavy equipment
Standing
Environmental conditions
Operation of motor vehicles
Use of public transportation
Kneeling
Personal protective equipment
Use of upper extremities
Other (explain):
Describe/quantify the limitations:
How long will these limitations apply?
1-2 days
3-7 days
8-14 days
15+ days
Unknown at this time
N/A
3. With whom will you discuss the patient's returning to work and/or limitations?
with patient
with patient's employer
N/A
4. Would the patient benefit from vocational rehabilitation?
Yes
No
This form is signed under penalty of perjury.
Board Authorized Health Care Provider - Check one:
I provided the services listed above.
I actively supervised the health-care provider named below who provided these services.
Provider's name___________________________________________________ Specialty__________________________________
Board Authorized Health Care Provider signature:
/
/
Name
Signature
Specialty
Date
C-4.2 (10-15) Page 2 of 2
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