Form 113a - Summary Of Medical Record - Industrial Accident

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Form 113a Revised 3/2010
SUMMARY OF MEDICAL RECORD – INDUSTRIAL ACCIDENT
(Please attach additional pages if necessary)
Petitioner’s Name: _____________________________ Date of Industrial Accident: _____________
Employer’s Name: _____________________________
1. Diagnosis and Cause
Please identify each and every medical problem caused petitioner by the industrial accident at issue.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
2. Preexisting Causes
Does the petitioner suffer from a pre-existing medical condition that contributed to the medical
problems identified by you in your answer to question No. 1 as caused by the industrial accident at
issue? ___Yes ____No
If yes, please explain:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
3. Work Release/Medical Stability
Have you released the petitioner from work as the result of the medical problems caused by the
industrial accident at issue? ___Yes ____No
If yes, on what date? __________________________
Have you released the petitioner to work with medically prescribed functional limitations (“light
duty”) as the result of the medical problems caused by industrial accident at issue? ___Yes ____No
If yes, on what date? _____________________ If yes, describe in detail the functional limitations?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Have you released the petitioner to return to work with no restrictions? ___Yes ____No
If yes, on what date? ________________________________________________________________
Is the petitioner medically stable (stabilization means that the period of healing has ended and the
condition of the petitioner will not materially improve) with respect to the medical problems caused by
the industrial accident at issue? ___Yes ____No
If yes, on what date (please identify separately a specific date of medical stability for each medical
problem if more than one caused by the industrial accident at issue.)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

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