Free   - Wisconsin

PHYSICIAN'S REPORT ON EYE INJURIES
Refer to Ind. 80.26, Loss of vision; determination

Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://dwd.wisconsin.gov/wc e-mail: [email protected]

Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes].

PATIENT

WC Claim Number Social Security Number Injury Date Date of First Treatment

Employee Name Employee Address Employer Name Date of Last Treatment or Exam Yes No If yes, explain. Insurance Company Name Which eye is injured? Right Left Both

HISTORY

If only one eye is injured, is the other eye affected? Please be as detailed as possible:

NATURE OF INJURY AND DIAGNOSIS

Is physical condition of the eyes stationary? Yes No If no, explain:

1) 2)

Have all adequate and reasonable operations Yes No been attempted?

3)

Did cataract form as a result of injury? Yes No If cataract formed, was lens removed? Yes No Has there been a surgical implant of lens? Yes No

Danger of further impairment? Yes No If yes, explain:

CENTRAL VISUAL READINGS
IMPORTANT: PLEASE FILL OUT EACH LINE COMPLETELY FOR EACH EYE

Distance Near

Use Snellen test letters or characters up to 20/800. Use AMA Reading Card up to 14/560. After Injury Pre-existing before injury, including presbyopia and other conditions clearly not the result of the injury. Without Correction Distance Near
Right Left

Without Correction Distance Near
Right Left

With Correction Distance Near

With Correction Distance Near

PRIOR DISABILITY

Did the employee wear glasses for pre-existing subnormal vision? Is there a record or positive indication of pre-existing subnormal vision? Is the remaining impairment due to the injury? Is there absence of useful binocular vision?

Yes Yes Yes

No No If yes, Explain: No Explain:

BINOCULAR VISION

Yes

No

Explain cause: _____________________________________________________________________________________________ If a result of the injury, what is the percentage of additional permanent disability? Industrial Motor Field Chart

Is there any diplopia present?

Yes

No

If yes, this should be plotted in the chart at the right by placing an X in each square in which diplopia is found. The test is to be made with any industrially useful correction applied. Was such correction used?

Yes

No

WKC-16-A (R. 03/2009)

FIELD VISION

Field vision taken without correction if possible using a white test object which subtends one degree and a standard perimeter with a radius of 12.9 inches (330 mm). The test object shall measure 0.223 inches (5.8 mm). Is there any loss of the field of vision? Yes No Is it the result of the injury? Yes No If so, indicate on the charts and table below. Sketch impaired area. Sketch areas of any scotomata.

When did the last trace of inflammation disappear from the eye?

______________________________________________________

Date able to return to work: _____________________________________________

_______________________________________________________________________________________ OTHER FUNCTIONS
Certain ocular disabilities are not covered in the foregoing sections, such as disturbance of accommodation, of color vision, of adaptation to light and dark, metamorphosia, entropion, ectropion, lagophthalmos, epiphora, and muscle disturbances not included under diplopia. Is any such disability present? If so, explain under "Remarks" below, stating whether it results from the injury, what it is, which eye, or whether both eyes are affected, and your percentage estimate of the impairment of the eye or eyes for industrial use. __________________________________________________________________________________________
_________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Remarks:

__________________________________________________________________________________________

Doctor Signature:

_______________________________________________________ Date Signed: _____________________
(Required in doctor's own handwriting)

Address:

_____________________________________________________________________________________________