Fill and Sign the Permanent Report Form

Last Name       Middle Initial      First Name              Date of Birth       Address                   Occupation       Social Security Number       Phone No,       Name       Phone Number       Address                         Name       Phone Number       Address                               Last date       Date of current       Permanent &                   STATE OF CALIFORNIA Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-3) This form is designed to be used by the primary treating physician to report the initial evaluation of permanent disability to the claims administrator. It should be completed if the patient has residual effects from the injury or may require future medical care. In such cases, it should be completed once the patient's condition becomes permanent and stationary or has reached maximum medical improvement. This form should not he used by a Qualified Medical Evaluator (QME) or Agreed M edical Evaluator (AME) to report A medical- legal evaluation. leg,11 e-'Au'llion Patient: Se x Cit y State Zip Claims Administrator/Insurer: City State Zip Emplover: City State Zip You must address each of the issues below. Use of this form is optional. You may substitute or append a narrative report if you require additional space to adequately report on these issues. Date of Injury Date worked Date examination Date Stationary date Dat e Description of how iniurv/illness occurred (e.g. Hand caught in punch press; fell from height onto back; exposed 25 years ago to asbestos):Patient's Complaints: DWC PR - 3 (Rev. 1/1/01)                         I .      2.       3.       4.                                     STATE OF CALIFORNIA Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-3) Relevant Medical Historv: Objective Findings:Physical Examination: (Describe all relevant findings; include any specific measurements indicating atrophy, range of motion, strength, etc.; include bilateral measurements - injured/uninjured - for upper and lower extremity injuries.) Diagnostic tests results (X-ray/Imaging/Laboratory/etc.) Diagnoses (List each diagnosis; ICD-9 code must be included) ICD-9 Yes No Cannot determine Did work cause or contribute to the injury or illness? Apportionment: Are there pre-existing impairments/disabilities that contribute to permanent disability? If Yes, append narrative to describe cause and extent of pre-existing disability; describe any documentation of pre-existing disability. Can this patient now return to his/her usual occupation? If not, can the patient perform another line of work? DWC Form PR-3 (Rev. 1/1/01) 2                                                                                                                             STATE OF CALIFORNIA Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-3)Subjective Findings: Provide your professional assessment of the subjective factors of disability, based on your evaluation of the patient's complaints, your examination, and other findings. List specific symptoms (e.g. pain right wrist) and their frequency, severity, and/or precipitating activity using the following definitions: Severity: Minimal pain (Min) - an annoyance, causes no handicap in performance. Slight pain (Slt) - tolerable, causes some handicap in performance of the activity precipitating pain. Moderate pain (Mod) - tolerable, causes marked handicap in the performance of the activity precipitating pain. Severe pain (Sev) - precludes performance of the activity precipitating pain.Frequency: Occasional (Occ) - occurs roughly one fourth of the time. Intermittent (Int) - occurs roughly one half of the time. Frequent (Fre) - occurs roughly three fourths of the time. Constant (Con) - occurs roughly 90 to I 00% of time. Precipitating activity: Precipitating activity gives a sense of how often a pain is felt and thus is often provided in lieu of frequency, e.g. slight pain in back on heavy lifting, or slight-to-moderate pain in knee when standing or walking more than six hours per day. Can be used in conjunction with frequency if pain is less than constant while engaging in the precipitating activity. For example, intermittent slight pain on bending would be felt approximately 50% of time while actually engaged in bending. Symptom Frequency Severity Precipitating (Mark X at any spot) (Mark X at any spot.) Activit y Occ Int Fr e Con Min Sl t Mod Sev Occ Int Fr e Con Min Sl t Mod Sev Occ Int Fr e Con Min Sl t Mod Sev Occ Int Fr e Con Min Sl t Mod Sev Yes No Cannot determine Pre-Injury Capacity Are there any activities at home or at work that the patient cannot do as well now as could be done prior to this injury or illness? If yes, please describe pre-injury capacity and current capacity (e.g. used to regularly lift 30 lb. child, now can only lift 10 lbs.; could sit for 2 hours, now can only sit for 15 mins.) 1. 2. 3. 4. DWC Form PR-3 (Rev. 1/l/01) 3                                                STATE OF CALIFORNIA Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-3) Preclusions/Work Restrictions Yes N o Cannot determine Are there any activities the patient cannot do?If yes, please describe all preclusions or restrictions related to work activities (e.g. no lifting more than 10 lbs. above shoulders; must use splint; keyboard only 45 mins. per hour; must have sit/stand workstation; no repeated bending). Include restrictions which may not be relevant to current job but may affect future efforts to find work on the open labor market (e.g. include lifting restriction even if current job requires no lifting; include limits on repetitive hand movements even if current job requires none), I . 2. 3. 4. 5. 6. Future Medical Treatment: Describe any medical treatment related to this injury that you believe the patient may require in the future. Include medications, surgery, physical medicine services, durable equipment, etc. Comments: DWC Form PR-3 (Rev. 1/1/01) 4 A. Name       B. Name       C. Name       Specialty       Specialty       Specialty                                                                                                                                                                                     Cal. Lic. # -       Executed at :             Name (Printed):       Specialty:       Address :                         Telephone:       STATE OF CALIFORNIA Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-3) List any other physicians who contributed information used in this report: List information you reviewed in preparing this report, or relied upon for the formulation of your medical opinions: Medical Records Personnel RecordsWritten Job Description Any other, please describe: Primary Treating Physician (original signature, do not stamp) I declare under penalty of perjury that this report is true and correct to the best of my knowledge, and that I have not violated Labor Code § 139.3. Signature : Date: (County and State) City: State: Zip : DWC Form PR-3 (Rev. 1/1/01) 5