Free APPENDIX A - Tennessee

FORM C-32 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

Division of Workers' Compensation
220 French Landing Drive Nashville, Tennessee 37243-1002

STANDARD FORM MEDICAL REPORT FOR INDUSTRIAL INJURIES
(Please type or neatly print all responses)

A. 1. 2. 3. 4. 5. 6.

PATIENT INFORMATION Name: Address: Social Security Number Date of Exam(s) Date of Birth Treating Physician Evaluating Physician [ [ ] ]

- Upon Whose Request: __________________________________________________________ - Date of Request: ______________________________________________________________ B. PATIENT HISTORY Include pertinent history of injury along with current treatment, hospitalization(s) and period(s) claimant unable to work.

C.

PHYSICAL EXAMINATION Include chief complaints and state all findings relative to the injury.

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D.

SUMMARY OF DIAGNOSTIC TESTING In the space below, check the applicable blocks next to any test results which you reviewed and relied upon to base your medical assessments or conclusions. Be sure to show the date of each test, and summarize results. Attach copy(s) of reports, if available. TEST X-RAY EMG CT SCAN MYELOGRAM MRI OTHERS DATE SUMMARY OF RESULTS

E.

SURGICAL PROCEDURES

Please specify (Attach Operative Note)

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F. IMPAIRMENT

1.

As a result of this injury, did the claimant suffer temporary total disability? Yes___ No ___ If yes, please provide the period(s) of time during which the claimant was temporarily totally disabled. From From From From To To To To

2.

Please provide the date on which the claimant was released to return to work. Return to work date: _______________ Please provide the date on which the claimant reached maximum medical improvement (MMI). Date of MMI: _________________

3.

4. Using the AMA's Physicians Guide to Evaluation of Permanent Impairment (latest edition available) or the Manual of Orthopedic Surgeons In Evaluating Permanent Physical Impairment, please translate the claimant's condition to a percentage of impairment. __________________ % scheduled member ____________ % whole body NOTE: Be sure to include all references to both Chapters 1 and 2 of the Guidelines. If chapter 2 is not used, please specify why it is not appropriate in this evaluation. What tables did you use in arriving at this percentage? Table_____________ Table_____________ Table_____________ Page _____________ Page _____________ Page _____________ Table ____________ Table ____________ Table ____________ Page _____________ Page _____________ Page _____________

NOTE: Please explain specifically how you arrived at the above calculation. 5. If you feel that the AMA Guide or the Orthopedic Manual does not adequately assess the medical impairment of the Claimant, please express an impairment that you think is appropriate for this patient. Please explain how you arrived at this percentage:

__________________% scheduled member 6.

____________% whole body

Considering the nature of Claimant's occupation and medical history along with diagnosis and treatment, does this injury more probably than not arise out of the claimant's employment? Yes ___ No ____
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G. FUNCTIONAL CAPACITY ASSESSMENT LIMITED, BUT RETAINS MAXIMUM CAPACITIES TO: Lift (including upward pulling) and/or CARRY: [ ] 10 lbs. [ ] 15 lbs. [ ] 20 lbs. [ ] 25 lbs. [ ] 30 lbs. [ ] 35 lbs. [ ] 40 lbs. [ ] 45 lbs. [ ] 50 lbs. or more FREQUENTLY LIFT and/or CARRY: [ ] 10 lbs. [ ] 15 lbs. [ ] 20 lbs. [ ] 35 lbs. [ ] 40 lbs. [ ] 45 lbs.

[ ] 25 lbs. [ ] 30 lbs. [ ] 50 lbs. or more

OCCASIONALLY LIFT and/or CARRY: [ ] LESS than ABOUT 3 hrs. (If marked limitation, explain) [ ] LESS than 10 lbs. (e.g. files, ledgers, small tools, etc.) STAND and/or WALK A TOTAL OF: [ ] LESS than ABOUT 3 hrs. (If marked limitation, explain) [ ] LESS than ABOUT 6 hrs. (If marked limitation, explain) [ ] ABOUT 6 hrs. (Per 8-hr. day) SIT A TOTAL of: [ ] LESS than ABOUT 3 hrs. (If marked limitation, explain) [ ] LESS than ABOUT 6 hrs. (If marked limitation, explain) [ ] ABOUT 6 hrs. (Per 8-hr. day) PUSH and/or PULL (Including hand/or foot controls): [ ] UNLIMITED [ ] LIMITED (Describe degree of limitation) PHYSICAL FACTORS: Frequently [ ] [ ] [ ] [ ] [ ] [ ] [ ] Occasionally [ ] [ ] [ ] [ ] [ ] [ ] [ ] Never [ ] [ ] [ ] [ ] [ ] [ ] [ ] Unlimited Reaching [ ] Handling [ ] Fingering [ ] Feeling [ ] Seeing [ ] Hearing [ ] Speaking [ ] Limited [ ] [ ] [ ] [ ] [ ] [ ] [ ]

Climbing Balancing Stooping Kneeling Crouching Crawling Twisting

Describe in what ways the impaired activities are limited: _______________________________ _____________________________________________________________________________ Environmental Restriction (e.g. heights, machinery, temperature extremes, dust, fumes, humidity, vibration, etc.): [ ] None [ ] Yes (Describe below)

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H. PHYSICIAN CERTIFICATION AND QUALIFICATIONS

I certify that the information furnished is correct and am aware that my signature attests to its accuracy. I further certify that all opinions are formulated within a reasonable degree of medical certainty. I further certify that my statement of qualifications is attached and that it is accurate.

Signature: _____________________________________________ Date: _________________ Please type full name of physician _________________________________________________ (Please attach a copy of the physicians statement of qualifications.)

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CLAIMANT'S CHRONOLOGICAL MEDICAL HISTORY

NAME & ADDRESS OF PHYSICIAN OR HOSPITAL

DATE TREATMENT RECEIVED

NATURE OF THE INJURY DISEASE? PART OF BODY AFFECTED? STILL UNDER DOCTOR'S CARE?

1.

2.

3.

4.

___________________________

DATE

______________________________________________________ PLAINTIFF SIGNATURE

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