Fill and Sign the Report Psychological Template Form

FORM 107 - P Medical Report - Psychological Revised April 2005 COMMONWEALTH OF KENTUCKY OFFICE OF WORKERS’ CLAIMS MEDICAL REPORT OF DR. _______________________________ A. PLAINTIFF INFORMATION 1. Plaintiff’s name: _________________________________________________________________________ 2. Address: _______________________________________________________________________________ 3. Social Security number: ___________________________________________________________________ 4. Date of birth: ____________________________________________________________________________ 5. Plaintiff’s job title and employer: ____________________________________________________________ 6. Date of examination(s): _____________________________20____ 7. Purpose of examination:  Treatment  Evaluation requested by ______________________________________   University evaluation 8. Prior Evaluation by this Physician (if any) and Date: _____________________________________________ B. PLAINTIFF HISTORY Plaintiff related history of psychological complaints or alleged condition as follows: C. TREATMENT – Prior and Current Do not write in this space FILED: Based upon a review of records and/or history related by plaintiff, treatment provided for this psychological condition has been as follows: (Include any periods of hospitalization.) D. PHYSICAL EXAMINATION/MENTAL STATUS EXAMINATION Results of physical examination (if any) including any objective medical findings, and results of mental status examination. E. DIAGNOSTIC TESTING Check the applicable block for any testing reviewed and relied upon for medical conclusions. Test Date Summary of Results  Neuropsychological (e.g., Luria-Nebraska, Halstead-Reitan)  Academic/Achievement (e.g., WRAT-R)  Intellectual Capacity (e.g., WAIS-R, etc.)  Personality (e.g., MMPI, Millon, etc.)  Brain Imaging (MRI, CT, SPECT)  Other (specify) F. DIAGNOSIS Utilize classification system of DSM-IV unless there is insufficient information to provide accurate impression. G. CAUSATION Within reasonable medical/psychological probability, was plaintiff's psychological complaints the direct result of the physical work-related injury?  Yes  No 107-P H. EXPLANATION OF CAUSAL RELATIONSHIP Explain how the physical work-related injury caused the psychological, psychiatric, or stress-related change in the human organism diagnosed above. I. IMPAIRMENT 1. Using Chapter 14 of the most recent AMA Guides to the Evaluation of Permanent Impairment , the plaintiff's classification of impairment is Class ___________. . 2. The plaintiff’s percentage of whole body impairment is %, calculated as follows: (Note: if prior editions are utilized in arriving at the impairment rating, indicate the edition.) Chapter Table Page Edition (year) a. b. c. 3. Plaintiff had an active psychological impairment prior to this injury.  Yes  No A. For affirmative answer, specify condition producing active impairment. ____________________ ______________________________________________________________________________ B. For affirmative answer, specify percentage of whole person impairment due to the prior active condition.________ 4. Date on which maximum medical improvement was reached due to psychiatric condition: ______20___ J. RESTRICTIONS 1. The plaintiff described the physical and mental requirements of the type of work performed at the time of injury as follows: 2. What physical, mental, or social restrictions (if any) should be placed upon the plaintiff as the result of the work injury? 3. Does plaintiff retain the physical capacity to return to the type of work performed at the time of injury?   Yes  No K. CERTIFICATION and QUALIFICATIONS of PHYSICIAN/PSYCHOLOGIST I hereby certify that the above information is correct and that all opinions were formulated within the realm of reasonable medical/psychological probability. A copy of my curriculum vitae is attached if I have not 107-P obtained an Office of Workers’ Claims Physician Index Number. Date: _______________________ __________________________________ Full name of Physician or Psychologist ________________________ Office of Workers’ Claims Physician Index Number 107-P Instructions for Completion of Form 107-I, 107-P, 108-OD, 108-CWP and 108-HL The medical report forms of the Office of Workers’ Claims are designed to provide relevant medical information to administrative law judges to assist in determining the occupational implications of a work-related injury or an occupational disease. Therefore, it is important that each section of the forms be carefully and fully completed. 1. All information must be typed or neatly printed. 2. The Office of Workers’ Claims maintains a Physician Index with curricula vitae of physicians. Physicians may be included in the index by tendering a copy of a current curriculum vitae with a request for inclusion to: Physicians Index Clerk, Office of Workers’ Claims , 657 Chamberlin Avenue, Frankfort, Kentucky 40601. 3. Use of the most recent edition of the AMA Guides to the Evaluation of Permanent Impairment is mandated by statute. Reference should be made to page numbers and tables only from the most recent edition for all physical injuries. For psychiatric conditions, the class of impairment should be stated, with reference to impairment ratings provided in prior editions. 4. For Forms 108, the height of a plaintiff should be measured in centimeters and without shoes. If the plaintiff’s height is an odd number of centimeters, the next highest even height in centimeters shall be used. 5. Objective medical findings to support a medical diagnosis means information gained through direct observation and testing of the plaintiffs, applying objective or standardized methods. KRS 342.0011(33). 6. Medical opinions must be founded on reasonable medical probability, not on mere possibility or speculation. Young v. Davidson , Ky., 463 S.W.2d 924 (1971). 7. Pre-existing dormant non-disabling condition is defined as a condition which is capable of arousal into disabling reality by work activities or injury. The condition must be a departure from the normal state of health. KRS 342.020, Newberg v. Armour Food Co. , Ky., 834 S.W.2d 172 (1992). 8. Any person who knowingly and with intent to defraud any insurance company or other person files a statement or claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Revised 1/26/05 107-P 107-P