Fill and Sign the Form 1132000doc

Form 113 Revised 2/2000 STATE OF UTAH - LABOR COMMISSION Division of Adjudication 160 East 300 South, 3rd Floor, P. 0. Box 146615 Salt Lake City, Utah 84114-6615 (801) 530-6800 (800) 530-5090 Fax (801) 530-6333 SUMMARY OF MEDICAL RECORD (To be completed by treating physician.) PATIENT NAME: DOB: S.S. #: ___________ DATE OF INJURY: EMPLOYER:__________________________________________________ 1. Has patient been released for usual work? What date? _____________________ 2. Has patient been released for light duty? What date?______________________ 3. Patient was required to be off work from to _____________________________ 4. Does patient have a permanent injury? If so, describe fully: _____________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________ 5. In case of permanent injury, on what date did or will the patient reach a final state of recovery? ______________________ 6. If there is a permanent injury, give your estimate of impairment in terms of percentage of loss of function:_______________ __________________________________________________________________________________________________ 7. Is there medically demonstrative causal relationship between the industrial accident and the problems you have been treating? Yes No Please explain as necessary:__________________________________________________________ ___________________________________________________________________________________________________ 8. What future medical treatment will be required as a result of the industrial accident? _______________________________ __________________________________________________________________________________________________ 9. What is the percentage of permanent physical impairment attributable to previously existing conditions, whether due to accidental injury, disease or congenital causes? _____________________________________________________________ __________________________________________________________________________________________________ 10. What is the patient's total physical impairment, if any, resulting from all causes and conditions, including industrial injury? __________________________________________________________________________________________________ __________________________________________________________________________________________________ 11. Did the industrial injury aggravate the patient's pre-existing condition? Please explain as necessary. __________________________________________________________________________________________________ __________________________________________________________________________________________________ DATED THIS DAY OF , 20 ___________________________________________ Physician’s Name (please print) Physician’s Specialty ___________________________________________ Physician's Signature Physician’s Street Address ___________________________________________ Physician’s City/State/Zip Physician's Telephone Number