Fill and Sign the Functional Progress Washington Form

                                                                    / /Department of Labor & IndustriesPO Box 44291 Olympia WA 985044291 Please return this form to L&I at the address above for state fund claims OR mail it directly to the self-insured company for self-insured claims. FUNCTIONAL PROGRESS FORM Though voluntary, the attending physician is strongly encouraged to use this form to track the patient's progress overtime. How can I help my patient regain function and return to work? 1. At each office visit, use this form to chart your patient's functional progress. 2. Speak with the employer (or potential employers) to explore light-duty and/or modified work. Remember $5,000 may be available for job modifications. 3. Ask for help from the claim manager and/or nurse consultant (1-800-848-081 1). 4. When your patient's progress has reached a plateau: please consider a consult. Or, if you feel the patient has reached maximum medical improvement, please consider doing an impairment rating or ask the department to obtain an independent medical examination. 5. For more information, see pages 9 - 14 of the Attending Doctor's Handbook (available at 1-800-848-081 1). Patient name Date of injury L&I Claim number Employer Contact and phone: Vocational Counselor and phone: Claim Manager and phone: Nurse Consultant at L&I and phone: For what diagnosis(es) are you using opioids? Start date of treatment Graph 1: Pain Summary (When treating with opioids, this estimate is the answer to question #1 in ''Opioid Progress Report Supplement") 10= Worst 10 i possible pain 8 6 4 2 0 = No pain 0 PLACE DATE OF OFFICE VISIT ON SLANTED LINES 10 = Levelof functionprior toinjury 10 5 = Partiallyrecovered 8functionsince injury 6 4 0 = Severeimpact onfunction at 2home orwork. 0 Graph 2- Functional Progress Summary (When treating with opioids, this estimate is the answer to question #6b in ''Opioid Progress Report Supplement.") F245-363-000 (PDF) finactional progress 12-99