Form Pr-3 - Primary Treating Physician'S Permanent And Stationary Report (Page 3 of 8) in pdf

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

STATE OF CALIFORNIA

Division of Workers’ Compensation

PRIMARY TREATING PHYSICIAN’S PERMANENT AND STATIONARY REPORT (PR-3)

Subjective Findings: Provide your professional assessment of the subjective factors of disability, based on your evaluation of the

patient’s complaints, your examination, and other findings. List specific symptoms (e.g. pain right wrist) and their frequency,

severity, and/or precipitating activity using the following definitions:

Severity:

Minimal pain - an annoyance, causes no handicap in performance.

Slight pain - tolerable, causes some handicap in performance of the activity precipitating pain.

Moderate pain - tolerable, causes marked handicap in the performance of the activity precipitating pain.

Severe pain - precludes performance of the activity precipitating pain.

Frequency:

Occasional - occurs roughly one fourth of the time.

Intermittent - occurs roughly one half of the time.

Frequent - occurs roughly three fourths of the time.

Constant - occurs roughly 90 to 100% of time.

Precipitating activity: Description of precipitating activity gives a sense of how often a pain is felt and thus may be used with

or without a frequency modifier. If pain is constant during precipitating activity, then no frequency modifier should be used.

For example, a finding of “moderate pain on heavy lifting” connotes that moderate pain is felt whenever heavy lifting occurs.

In contrast, “intermittent moderate pain on heavy lifting” implies that moderate pain is only felt half the time when engaged in

heavy lifting.

Yes

Cannot

determine

Pre-Injury Capacity

Are there any activities at home or at work that the patient cannot

do as well now as could be done prior to this injury or illness?

If yes, please describe pre-injury capacity and current capacity (e.g. used to regularly lift a 30 lb. child, now can only lift 10 lbs.;

could sit for 2 hours, now can only sit for 15 mins.)

DWC Form PR-3 (Rev. 01/01/05)

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