Form Pr-3 - Primary Treating Physician'S Permanent And Stationary Report Page 2

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STATE OF CALIFORNIA
Division of Workers’ Compensation
PRIMARY TREATING PHYSICIAN’S PERMANENT AND STATIONARY REPORT (PR-3)
Relevant Medical History:
Objective Findings:
Physical Examination: (Describe all relevant findings; include any specific measurements indicating atrophy, range of motion,
strength, etc.; include bilateral measurements - injured/uninjured - for upper and lower extremity injuries.)
Diagnostic tests results (X-ray/Imaging/Laboratory/etc.)
Diagnoses (List each diagnosis; ICD-9 code must be included)
ICD-9
1.
2.
3.
4.
Yes
No
Cannot
determine
Can this patient now return to his/her usual occupation?
If not, can the patient perform another line of work?
DWC Form PR-3 (Rev. 01/01/05)
2

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