Attending Physician'S Statement Additional Report - Psychological Illness Page 2
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2Attending Physician's Statement Additional Report
Physical Illness
For psychological illness, complete the other side of this form.
IDENTIFICATION
(the insured must complete this section)
Last name: ______________________________________ First Name: ___________________________________ Date of Birth: _____________________
Policy No: ____________________________________________________ Public Health Insurance No: ________________________________________
(complete in block letters and give to the patient)
ATTENDING PHYSICIAN’S STATEMENT
1. DIAGNOSIS
1.1. Primary: ___________________________________________________ Code CIM-9: ________________________________________________
1.2. Secondary: __________________________________________________ Code CIM-9: ________________________________________________
1.3. Objective elements of the physical examination and investigation (attach copy of recent results, x-rays, ECG, or other tests or examinations):
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Weight: ❑ lb ❑ kg
Height: ❑ ft/in ❑ m/cm
Most recent blood pressure: ___________________________________________________
1.4. Degree of the symptom’s severity (M=mild, Md=moderate, S=severe):
M
Md
S
M
Md
S
___________________________________________
___________________________________________
___________________________________________
___________________________________________
2.TREATMENT
2.1. Medication – name and dosage: ____________________________________________________________________________________________
_______________________________________________________________________________________________________________________
2.2. Additional treatments (specify the type and frequency): __________________________________________________________________________
2.3. Surgery (date, nature and procedure): ________________________________________________________________________________________
2.4. Hospitalization from: __________________ to ___________________ Name of hospital: _______________________________________________
2.5. Consultation with a specialist: ❑ yes ❑ no
Attach copy
3. FOLLOW-UP AND PROGNOSIS
3.1. Date of last consultation for this disability: _______________________________ Date of next consultation: ________________________________
3.2. Tests and examinations to come: ____________________________________________________________________________________________
3.3. Frequency of follow-up: ___________________________________________________________________________________________________
3.4. Referral to a specialist: ❑ yes ❑ no
Name of physician: ____________________________________________________________________
3.5. Scheduled date of consultation with a specialist: _____________________________________ Specialty: __________________________________
3.6. Describe functional limitations that prevent the patient from carrying out professional duties or usual activities.
At the beginning of disability
Currently
__________________________________________________________
____________________________________________________________
__________________________________________________________
____________________________________________________________
3.7. Evolution: ❑ progressive
❑ stable
❑ regressive
3.8. If you anticipate that the absence from work will exceed the usual period for such a diagnosis, please specify the factors justifying your prognosis.
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
3.9. Patient’s cooperation in the treatment: ❑ excellent
❑ average
❑ poor
3.10. Would your patient benefit from assistance within the scope of a return to work? ❑ yes ❑ no
3.11. Approximate duration of disability: __________days __________weeks
❑ To be determined or date of return to work: _____________________
3.12. How long before the patient will be able to return to work? _________days __________weeks
❑ part-time
❑ full-time
❑ gradual return Specify: ___________________________________________________________________________
- Please add any comments that would help us better understand your patient’s medical condition.
4. COMMENTS
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
STATEMENT
First and Last name: ______________________________________________________________ Telephone: _________________________________
Address: _______________________________________________________________________ Fax: _______________________________________
❑ General practitioner ❑ Specialist Please specify: ____________________________________ Licence No: _________________________________
Signature: ______________________________________________________________________ Date: ______________________________________
day /month/ year
Note: The claimant must pay any fees requested to complete this form.
01QRI0054A (02-13)
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