Doctors First Report Of Occupational Injury Or Illness California Page 2
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3STATE OF CALIFORNIA
DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS
20. DIAGNOSES(if occupational illness specify etiologic agent and duration of exposure.) Chemical or toxic compounds involved?
1.
ICD-10
2.
ICD-10
3.
ICD-10
4.
ICD-10
5.
ICD-10
6.
ICD-10
7.
ICD-10
8.
ICD-10
9.
ICD-10
10.
ICD-10
11.
ICD-10
12.
ICD-10
21. Are your findings and diagnosis consistent with patient's account of injury or onset of illness?
If "no," please explain below:
22. Is there any other current condition that will impede or delay patient's recovery?
If "yes," please explain below:
23. TREATMENT RENDERED (Use reverse side if more space is required.)
24. If further treatment required, specify treatment plan/estimated duration.
25. If hospitalized as inpatient, give hospital name and location
Date admitted
Estimated length of stay
Yes
No
26. WORK STATUS - Is patient able to perform usual work?
If "no", date when patient can return to
Regular work
Modified work
Specify restrictions
Form 5021 (Rev. 5) 10/2015
Sheet 2 of 3
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Parent category: Medical