Musculoskeletal Attending Physician Statement Form Page 2
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1
2Part IV: FACTORS AFFECTING RECOVERY
Current
height ________________ weight ________________
General fitness _____________________________________________________________________________________________________
Addiction __________________________________________________________________________________________________________
Diet ______________________________________________________________________________________________________________
Work environment ___________________________________________________________________________________________________
Home environment __________________________________________________________________________________________________
Past medical history _________________________________________________________________________________________________
Pre-existing conditions _______________________________________________________________________________________________
Family history of present condition ______________________________________________________________________________________
Has the patient previously had a similar condition?
Yes
No
If yes, specify date of initial onset _________________________________
DATE (YYYY | MM | DD)
PART V: MANAGEMENT PLAN FOR THE CURRENT CONDITION
DATE (YYYYIMMIDD)
Frequency of visits ___________________________________________________________________
I
I_
Date of most recent visit _______________________________________________________________
I
I_______
Date of re-evaluation__________________________________________________________________
I
I_
Hospitalization dates - include admission/discharge summaries
______________________________________________________________________________________
I
I_
______________________________________________________________________________________
I
I_
______________________________________________________________________________________
I
I_
______________________________________________________________________________________
I
I_
Surgery date(s) and type(s) - include operative report(s)
_______________________________________________________________________________________
I
I_
_______________________________________________________________________________________
I
I_
_______________________________________________________________________________________
I
I_
Medication – include dosage
______________________________________________________________________________________
I
I_
______________________________________________________________________________________
I
I_
______________________________________________________________________________________
I
I_
Future treatment plans ___________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Additional diagnostic testing _______________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Name of other health care providers:
Specialty
Other specialists ______________________________ _____________________________________
I
I_
Counsellor ___________________________________ ____________________________________
I
I_
Therapist ____________________________________ _____________________________________
I
I_
Is the patient following recommended treatment program?
Yes
No If no, explain circumstances ________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
PART VI: ESTIMATED TIME FOR RECOVERY
1.
Patient progress
None
Regressed
Minimal Improvement
Significant Improvement
Plateaued
Resolved
Prognosis
Poor
Good
2.
Is the patient a suitable candidate for medical rehab services (i.e., conditioning program, counselling, etc.)?
Yes
No
Provide comments and recommendations. ________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
3.
In your opinion, is the patient a suitable candidate for a work re-entry program (i.e., ease-back, modified duties, gradual return to work, etc.)?
Yes
No
Provide comments and recommendations. ________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
4.
Any additional information or details that may have a significant impact on the patient’s recovery from this condition?
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Signature ______________________________________________________________________ Date ________________________________
® Saskatchewan Blue Cross is a registered trade-mark of the Canadian Association of Blue Cross Plans, used under license by Medical Services Incorporated, an independent licensee.
MSI 381 09/13
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