Musculoskeletal Attending Physician Statement Form
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1
2ATTENDING PHYSICIAN STATEMENT
ATTENDING PHYSICIAN STATEMENT
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MUSCULOSKELETAL
MUSCULOSKELETAL
PO Box 4030 Saskatoon SK S7K 3T2
PO Box 4030 Saskatoon SK S7K 3T2
306.244.1192 Toll-free in Saskatchewan 1.800.667.6853
306.244.1192 Toll-free in Saskatchewan 1.800.667.6853
Fax 306.652.5751
Fax 306.652.5751
Instructions
Instructions
1. Please print.
3. Part II–VI to be completed by physician.
1. Please print.
3. Part II–VI to be completed by physician.
2. Part I to be completed by
2. Part I to be completed by
patient.
patient.
4. Any fee for completing this form is the patient’s responsibility.
4. Any fee for completing this form is the patient’s responsibility.
PART I: PATIENT AUTHORIZATION
PART I: PATIENT AUTHORIZATION
_____
_____
I_____ I_______
I_____ I_______
Name ____________________________________________________________________________ Date of Birth
Name ____________________________________________________________________________ Date of Birth
Last
Last
First
First
Initial
Initial
YYYY
YYYY
MM
MM
DD
DD
I hereby authorize the release of any information herein requested by my insurer or its agent.
I hereby authorize the release of any information herein requested by my insurer or its agent.
Signature _____________________________________________________ Date _________________________
Signature _____________________________________________________ Date _________________________
PART II: ATTENDING PHYSICIAN
PART II: ATTENDING PHYSICIAN
Name ________________________________________________________________ Specialty _______________________________________
Name ________________________________________________________________ Specialty _______________________________________
Address ______________________________________________________________________________________________________________
Address ______________________________________________________________________________________________________________
Telephone _____________________________ Fax ______________________________ Email _______________________________________
Telephone _____________________________ Fax ______________________________ Email _______________________________________
Part III: HISTORY OF PRESENT CONDITION(S)
Part III: HISTORY OF PRESENT CONDITION(S)
1.
1.
a. Primary diagnosis ________________________________________________________________________________________________
a. Primary diagnosis ________________________________________________________________________________________________
b. Secondary diagnosis ______________________________________________________________________________________________
b. Secondary diagnosis ______________________________________________________________________________________________
__
__
I_
I_
_ I
_ I
_
_
c. Date symptoms first appeared or accident happened
c. Date symptoms first appeared or accident happened
YYYY
YYYY
MM
MM
DD
DD
__
I_
_I
_
__
I_
_I
_
d. Initial examination date
d. Initial examination date
YYYY
YYYY
MM
MM
DD
DD
__
__
I_
I_
I
I
_
_
e. Date patient ceased working due to this condition
e. Date patient ceased working due to this condition
YYYY
YYYY
MM
MM
DD
DD
f. Is condition due to injury or sickness arising from patient’s employment?
f. Is condition due to injury or sickness arising from patient’s employment?
Yes
Yes
No
No
Unknown
Unknown
Have workers compensation forms been completed?
Have workers compensation forms been completed?
Yes
Yes
No
No
Unknown
Unknown
g. Has patient ever had the same or similar conditions?
g. Has patient ever had the same or similar conditions?
Yes
Yes
No
No
If yes, state date(s) of previous incidence(s).
If yes, state date(s) of previous incidence(s).
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
2.
Symptoms (include severity & frequency)
2.
Symptoms (include severity & frequency)
Area
Area
Cervical
Cervical
Thoracic
Thoracic
Lumbosacral _____________________________________________________________________
Lumbosacral _____________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Clinical findings (attach copies of X-rays, CT SCAN/MRI, EMG, etc.)
Clinical findings (attach copies of X-rays, CT SCAN/MRI, EMG, etc.)
Distinct muscle spasm
Distinct muscle spasm
Loss or distortion of normal spine curvature
Loss or distortion of normal spine curvature
Neurological deficits: Power
Neurological deficits: Power
Yes
Yes
No If yes, degree __________________________________________________
No If yes, degree __________________________________________________
Sensory Loss
Sensory Loss
Yes
Yes
No If yes, degree __________________________________________________
No If yes, degree __________________________________________________
Reflexes
Reflexes
Yes
Yes
No If yes, degree __________________________________________________
No If yes, degree __________________________________________________
Range of motion:
Range of motion:
Forward flexion _________ degrees
Forward flexion _________ degrees
Rotation _________ degrees
Rotation _________ degrees
Lateral flexion __________ degrees
Lateral flexion __________ degrees
SLR ____________ degrees
SLR ____________ degrees
3.
3.
Restrictions and Limitations
Restrictions and Limitations
Functional capacity (duration in hours)
Functional capacity (duration in hours)
Sitting
Sitting
8
8
7
7
6
6
5
5
4
4
3
3
2
2
1
1
Other ____________________________________________________________________
Other ____________________________________________________________________
Standing 8
Standing 8
7
7
6
6
5
5
4
4
3
3
2
2
1
1
Other ____________________________________________________________________
Other ____________________________________________________________________
Walking
Walking
8
8
7
7
6
6
5
5
4
4
3
3
2
2
1
1
Other ____________________________________________________________________
Other ____________________________________________________________________
What specific factors, if any, interfere with the patient’s ability to sit, stand or walk? _____________________________ ___________________
What specific factors, if any, interfere with the patient’s ability to sit, stand or walk? _____________________________ ___________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
What devices might improve the patient’s ability to sit, stand or walk?
What devices might improve the patient’s ability to sit, stand or walk?
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Continuously
Frequently
Occasionally
Patient is able to
Frequency / Duration
Continuously
Frequently
Occasionally
Patient is able to
Frequency / Duration
Continuously
Continuously
Frequently
Frequently
Occasionally
Occasionally
Patient is able to
Patient is able to
Frequency / Duration
Frequency / Duration
Lift/Carry
Lift/Carry
Less than 10 lb/5 kg
Less than 10 lb/5 kg
Drive
Drive
Lift/Carry
Lift/Carry
Less than 10 lb/5 kg
Less than 10 lb/5 kg
Drive
Drive
More than 10 lb/5 kg
More than 10 lb/5 kg
Crouch
Crouch
More than 10 lb/5 kg
More than 10 lb/5 kg
Crouch
Crouch
More than 20 lb/10 kg
More than 20 lb/10 kg
Balance
Balance
More than 20 lb/10 kg
More than 20 lb/10 kg
Balance
Balance
More than 50 lb/25 kg
More than 50 lb/25 kg
Bend/Stoop
Bend/Stoop
More than 50 lb/25 kg
More than 50 lb/25 kg
Bend/Stoop
Bend/Stoop
Push/Pull
Push/Pull
Less than 10 lb/5 kg
Less than 10 lb/5 kg
Twist
Twist
Push/Pull
Push/Pull
Less than 10 lb/5 kg
Less than 10 lb/5 kg
Twist
Twist
More than 10 lb/5 kg
More than 10 lb/5 kg
Kneel/Squat
Kneel/Squat
More than 10 lb/5 kg
More than 10 lb/5 kg
Kneel/Squat
Kneel/Squat
More than 20 lb/10 kg
More than 20 lb/10 kg
Climb stairs
Climb stairs
More than 20 lb/10 kg
More than 20 lb/10 kg
Climb stairs
Climb stairs
More than 50 lb/25 kg
More than 50 lb/25 kg
Reach at shoulder level
Reach at shoulder level
More than 50 lb/25 kg
More than 50 lb/25 kg
Reach at shoulder level
Reach at shoulder level
Reach above shoulders
Reach above shoulders
Reach above shoulders
Reach above shoulders
Reach below shoulders
Reach below shoulders
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