Form Msi 379 - Bcbs Physician Statement - Cardiac
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1
2ATTENDING PHYSICIAN STATEMENT
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CARDIAC
PO Box 4030 Saskatoon SK S7K 3T2
306.244.1192 Toll-free in Saskatchewan 1.800.667.6853
Fax 306.652.5751
Instructions
1. Please print.
3. Part II–VI to be completed by physician.
2. Part I to be completed by
patient.
4. Any fee for completing this form is the patient’s responsibility.
PART I: PATIENT AUTHORIZATION
Name ___________________________________________________________ Date of Birth _________I_________ I________
Last
First
Initial
YYYY
MM
DD
I hereby authorize the release of any information herein requested by my insurer or its agent.
Signature _____________________________________________________ Date _________________________
PART II: ATTENDING PHYSICIAN
Name ________________________________________________________________ Specialty __________________________
Address _________________________________________________________________________________________________
Telephone __________________________ Fax __________________________ Email _________________________________
Part III: HISTORY OF PRESENT CONDITION(S)
1.
Specific cardiac diagnosis _______________________________________________________________________________
2.
Secondary diagnosis ___________________________________________________________________________________
3.
Date symptoms first appeared
__ I_
_ I
___
4. Initial examination date
__ I_
_ I
___
YYYY
MM
DD
YYYY
MM
DD
5.
Date patient ceased working due to this condition ____ I_ _ I
___
YYYY
MM
DD
6.
Symptoms (include severity & frequency) ___________________________________________________________________
____________________________________________________________________________________________________
_________________________________________________________________________________________________ _
7.
Clinical findings:
Chest pain of cardiac origin
Syncope
Fatigue
Dyspnea due to vascular congestion/hypoxia
Psychophysiology
Blood pressure readings (at least three) at onset of current condition __________________________________________
Other (please specify) _______________________________________________________________________________
_______________________________________________________________________________________________
8.
Laboratory/Diagnostic (attach copies of all relevant test results)
Laboratory/Diagnostic Testing
YYYY
MM
DD
YYYY
MM
DD
EKG
Echocardiogram
Stress Thallium Test
Pulmonary Function Test
Blood Test
X-rays
Other
9.
Current height
weight
Part IV: FACTORS AFFECTING RECOVERY
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 ____________________
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