ࡱ> 02/ bjbj 6 cc          , HHHHH###6888888$\\ #####\  HHq# H H6#6H0’DN-*"0W(  #######\\################ :  Human Resources Division Workers Compensation Section 100 Cambridge Street, Suite 600 Boston, MA 02114 PHYSICIANS REPORT Report status: Initial_____Follow-up _____ TO BE COMPLETED BY EMPLOYER: 1. Name of Facility/Agency phone ( )________________ Address:______________________________________________________________________________ Name/Title of Workers Compensation Contact:______________________________________________ TO BE COMPLETED BY EMPLOYEE: 2. Full Name ______________________________________________________Date of Birth:___/___/___ First Middle Last Address:_____________________________________________________________________________ 3. Date of Injury:___________________________________Social Security No.:_______-_____-_______ 4. Has employee received prior medical treatment for this injury? Yes_____ No_____ If yes, by whom?______________________________________________________________________ TO BE COMPLETED BY MEDICAL PROVIDER/OFFICE STAFF: 5. Physician Name (print or type):_____________________________________Date of Exam____/___/____ License No.:_________________Specialty:___________________________Date of Report___/___/____ 6. Mailing Address:______________________________________________________________________ TO BE COMPLETED BY PHYSICIAN(MEDICAL EXAMINATION RESULTS): Provide patients statement as to how the injury occurred:______________________________________ ____________________________________________________________________________________ 8. Is there a history/evidence of pre-existing injury/disease: Yes ______ No_______ If yes, explain:________________________________________________________________________ 9. Subjective Complaints:_________________________________________________________________ ____________________________________________________________________________________ 10. Objective Findings:____________________________________________________________________ ___________________________________________________________________________________ 11. Neurological Findings (if any):___________________________________________________________ _____________________________________________________________________________________ 12. Diagnosis:_____________________________________________________________________________ 13. Plan of Treatment:______________________________________________________________________ 14. In your opinion, was the accident/exposure a producing/contributing cause of the injury? Yes___ No____ 15. Is the employee able to perform his/her regular work duties? Yes____ No____ If no, employee may return to full duty in _________days/weeks. (Circle one) 16. FUNCTIONAL LIMITATIONS: Temporary modified work may be available at state facilities. The employer may develop a modified job based on any restrictions described below. Patient CANNOT: SIT more than _____hours/day STAND/WALK more than _____hours/day CARRY/LIFT more than ___10____20___30___40___50___lbs. PUSH more than ___10____20___30___40___50 ___lbs. PULL more than___ 10____20___30___40___50 ___lbs. DRIVE VEHICLE Yes_____ No_____ OTHER (please describe):________________________________________________________ 17. (Physician Referrals Only) Indicate Physician:________________________Specialty:_______________ SIGNATURE OF PHYSICIAN I certify under the pains and penalty of perjury that I have personally examined the above named employee. 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