Free Physicians Report on Eye Injuries (WC-241) - Missouri

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION

PHYSICIAN'S REPORT ON EYE INJURIES

3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058

NOTE: This report is required in each case of eye injury resulting in any degree of permanent disability so that a correct evaluation of the loss sustained may be made and the amount of compensation due for it accurately computed.

State's Number For:

File: Carrier: Employer:

Carrier's File No. IN ORDER FOR THIS FORM TO SERVE ITS PURPOSE, ALL DATA ASKED FOR MUST BE GIVEN.

Eye injuries not resulting in any permanent disability should be reported on the regular report form, Medical Treatment Form (WC-9).

The Patient

1. Name of Injured Person 2. Address City 3. Name and Address of Employer

Age

Sex

State

The Accident

4. Date of Accident

Hour

a.m. p.m.

Date disability began

5. State in patient's own words where and how accident occurred

The Injury

6. Which eye was injured? 8. Nature of injury and diagnosis

7. Is other eye affected by injury?

Yes

No

9. Is condition of eye(s) not stationary?

Yes

No Yes No

10. Have all adequate and reasonable operations and treatment been attempted? If "No," explain:

WC-241 (02-08) AI

I. CENTRAL VISUAL ACUITY READINGS
Without Any Corrective Lenses Distance 11. Right Eye 12. Left Eye Near With Correction Only for Natural Presbyopia and Other Conditions Clearly Not the Result of Injury Distance Near

II. FIELD OF VISION
NOTE: The field of vision shall be determined on a standard perimeter using white test target of 1 degree. 13. Is there any loss of field of vision? Yes No

14. Is it a result of injury? Yes No If "Yes," show below by tracing the reduced field in outline on the applicable figure and by giving reading found at the eight principal meridians in the center box.

III. BINOCULAR VISION
NOTE: Test is to be made without corrective lenses or prisms. 15. Is there useful binocular vision? Yes No Yes No

16. Is there any diplopia (double vision) present?

17. If "Yes," plot on the accompanying chart by placing an "X" in each rectangle where diplopia is present.

WC-241-2 (02-08) AI

IV. SECONDARY OCULAR DISABILITIES
18. If there are ocular disabilities other than those covered in the foregoing sections, please indicate them below by appropriate checking, and if any of the first three are checked indicate under "Remarks" your estimate of the percentage. If any secondary disability exists that is not listed, note it in the blank space provided. If there are no secondary disabilities, check this box A. Paralysis of Accommodation................................ B. Ectropion ......... or Entropion .............. H. Eye Brow (Complete Loss of) Unilateral..................................................................... Bilateral ....................................................................... I. Eye Lashes (Complete Loss of) Unilateral..................................................................... Bilateral ....................................................................... J. *Cataract (Traumatic).................................................. K. *Dislocation of Lens (Traumatic) Partial .......................................................................... Complete ..................................................................... L. Scotoma (Traumatic) ................................................... If NOT centrally located.............................................. M. __________________________________________ __________________________________________ __________________________________________ __________________________________________

Unilateral .............................................................. Bilateral ................................................................ C. Iridectomy (Traumatic or Surgical) Photophobia and Dazzling.................................... D. Lagophthalmos ..................................................... Unilateral .............................................................. Bilateral ................................................................ E. Epiphora Unilateral .............................................................. Bilateral ................................................................ F. Symblepharon (Also Limited Muscle Function) .. G. Ptosis Unilaterial ............................................................. Bilateral ................................................................

19. REMARKS

(over)
WC-241-3 (02-08) AI

V. PRE-EXISTING SUBNORMAL VISION
20. Is there record of adequate and positive indication of pre-existing subnormal vision? If "Yes," explain: Yes No

21. Is there likelihood of further impairment of the pre-existing subnormal vision, as a result of this injury? If "Yes," explain:

Yes

No

VI. CONDITIONS REQUIRING DELAYED FINAL EXAMINATION
In cases of disturbance of extrinsic ocular muscles, optic nerve atrophy, retained intraocular foreign body, injury to the retina, sympathetic ophthalmia and traumatic cataract, at least six months ­ preferable not more than from twelve months to sixteen months ­ must elapse before final examination shall be made on which this report is based. 22. If any of the conditions mentioned immediately above exist, is there likelihood of further impairment occurring as a result of the Yes No injury? If "Yes," explain:

23. Date of Examination 24. Doctor's Signature (Required in Doctor's own handwriting) 25. Address City

Date of Report

State
WC-241-4 (02-08) AI