Physiotherapy Initial Assessment Form

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Physiotherapy Initial
Please FAX this form IMMEDIATELY
Winnipeg: 954-4999
Assessment
Toll free: 1-877-872-3804
333 Broadway • Winnipeg R3C 4W3
Claim No.
Telephone 954-4922 • Toll free 1-800-362-3340
Worker Information
Last Name
First Name
Address
City
Province
Postal Code
Telephone No.
(
)
Date of Birth
Job Title
Name of Attending/Referring Physician
DD / MM / YYYY
Injury Details
Date of Incident
Area of Injury
Request for discussion with WCB
Yes
No
Physiotherapy Consultants?
DD / MM / YYYY
Date of Initial Assessment
Worker’s description of incident or injury
DD / MM / YYYY
Examination Findings & Diagnosis
Current Subjective Complaints
Self Assessment Tool (check tools used - minimum of 2)
Score:
Score:
Numeric Pain Rating Scale (NPRS)
______
Lower Extremity Activity Profile (LEFS)
_______
Roland Morris Back Pain Questionnaire (back)
______
Disabilities of the Arm, Shoulder and Hand (DASH)
_______
Neck Disability Index (neck)
______
Health Status Disability
_______
Current Objective Findings - Impairments
Specify:
Mobility
Yes
No
If yes, specify muscle groups involved
Strength
Yes
No
/5
Other (ligamentous, stability, edema, gait, neurological, etc)
Yes
No
If yes, specify:
Therapist’s Diagnosis on Completion of Assessment
Multisite request x _____ visits
(If approved requires scheduling double the normal
allotted treatment time)
Anticipated treatment
_______ /week x _______ weeks
Were findings/recommendations discussed with worker?
Yes
No
Was home program provided?
Yes
No
If yes, specify:
Work Capabilities
When can worker return to regular duties?
Will Worker be disabled from work beyond the
date of incident as a result of the injury?
Yes
No
Date
DD / MM / YYYY
Unknown at time of examination
Is Worker capable of alternate or modified work?
Yes
No
If yes, outline restrictions:
Duration of restrictions: _______ weeks
Therapist Information
Therapist Name
Telephone No.
Fax No.
(
)
(
)
Facility Name
Email
Date
DD / MM / YYYY
City
Province
Postal Code
Therapist Signature
Fax This Form
Winnipeg: 954-4999
Toll Free: 1-877-872-3804

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