Form M-1 - Diagnostic Medical Report - Maine Workers' Compensation Board - 2015
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2M-1 DIAGNOSTIC MEDICAL REPORT
MAINE WORKERS' COMPENSATION BOARD
EMPLOYER NAME:
EMPLOYER MAILING ADDRESS:
INSURER NAME:
INSURER MAILING ADDRESS:
CLAIM NUMBER (IF KNOWN):
THIRD PARTY ADMIN. NAME (IF APPL.):
THIRD PARTY ADMIN. MAILING ADDRESS (IF APPL.):
EMPLOYEE NAME:
SSN (last 4 digits only):
DOB:
DATE OF INJURY:
XXX-XX-
PATIENT COMPLAINTS:
DATE OF THIS EXAMINATION : ________________________________________
INITIAL
PROGRESS
FINAL
ICD-9
ICD-10 DIAGNOSIS:_____________________________________________________________________________________________________
IN MY OPINION, THIS DIAGNOSIS IS
WORK RELATED
NOT WORK RELATED
NOT YET IDENTIFIED AS TO CAUSE
HAVE DIAGNOSTIC TESTS BEEN PERFORMED?
YES
NO IF YES, LIST: ________________________________________________________
TREATMENT TO CONTINUE?
YES IF YES, DATE TO BE SEEN AGAIN:__________________
NO IF NO, PATIENT AT MMI?
YES
NO
ESTIMATED LENGTH OF TREATMENT ___________________
DAYS
WEEKS
MONTHS
TREATMENT PLAN (CHECK ALL THAT APPLY):
REST
MEDICATION
EXERCISE
MEDICAL REFERRALS:
THERAPY (LIST):_________________
SURGERY (LIST):_______________
OTHER(LIST):_________________
OFFICE PROCEDURES:
CAST
STRAPPING
OTHER (LIST): _________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
DOES TREATMENT PLAN INCLUDE MEDICATION THAT WOULD PREVENT THE PATIENT FROM DRIVING AND/OR WORKING SAFELY?
YES
NO
IF YES, LIST MEDICATIONS: _______________________________________________________________________________________________________
WORK CAPACITY:
REGULAR DUTY
NO WORK CAPACITY IF CHECKED, ESTIMATED DATE OF RETURN : ____________________________
MODIFIED WORK (DESCRIBE RESTRICTIONS BELOW) IF CHECKED, ESTIMATED LENGTH OF RESTRICTIONS? ____________________________
BODY PARTS:
ACTIVITY/USE OF:
RIGHT
LEFT
UPPER
LOWER
NEVER
MINIMAL
MODERATE
NORMAL
HEAD
LIFT/CARRY >
LBS
NECK
THORAX
WALKING
BACK
FLANK
STANDING
SPINE
STAIR CLIMBING
ABDOMEN
SITTING
SHOULDER
STOOP/BEND
HUMERUS
KNEEL/CRAWL
FOREARM
WRIST
PUSH/PULL
HAND
FINGERS
VIBRATORY TOOLS
PELVIS
HIP
REPETITIVE ACTIVITIES
FEMUR
KNEE
KEYBOARD USE
LEG
ANKLE
FOOT
TOES
OTHER_____________
NOT YET AVAILABLE
PERMANENT IMPAIRMENT EXPECTED?
YES
NO IF YES, PERMANENT IMPAIRMENT RATING
______ % OR
__________________________________________________________________
__________________________________________________________________________
SIGNATURE OF HEALTH CARE PROVIDER
PRINT NAME
ADDRESS _______________________________________
TELEPHONE #___________________________________________
M-1 (Effective 10/1/15)
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