Free Form 108-HL - Kentucky

FORM 108 - HL
Medical Report - Hearing Loss Revised April 2005

FILED:

KENTUCKY DEPARTMENT OF WORKERS CLAIMS MEDICAL REPORT OF DR. ___________________________

Do not write in this space

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PLAINTIFF INFORMATION Plaintiff's name: ______________________________________________________________________2. Address: ____________________________________________________________________________ Social Security number: ________________________________________________________________ Date of birth: ________________________________________________________________________ Plaintiff's job title and employer: ____________________________________________________________ Date of examination(s): ___________________________________________________________________ Purpose of Examination: Treatment Evaluation requested by ______________________________________ University evaluation Prior Evaluation by this Physician (if any) and Date: __________________________________________

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B. PLAINTIFF HISTORY Plaintiff related history of complaints allegedly due to hearing loss as follows:

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EMPLOYMENT HISTORY

Employment History (Form 104) dated is attached. Review form with plaintiff and list pertinent employment history, including exposure, if any, to environmental noise, either through a single incident of trauma or repetitive exposure over an extended period.

D. TREATMENT - Prior and Current Based upon a review of records and/or history related by plaintiff, treatment (including any periods of hospitalization) provided for the above complaints has been as follows:

E. PHYSICAL EXAMINATION Results of physical examination, including objective medical findings.

F. DIAGNOSTIC TESTING Check the applicable block for any testing reviewed and relied upon for medical conclusions. Test Comprehensive Audiometry Immitance Audiometry Otoacoustic Emissions Communication Needs Assessment Other (specify) G. DIAGNOSIS Date Summary of Results

H. 1.

CAUSATION Do audiograms and other testing establish a pattern of hearing loss compatible with that caused by hazardous noise exposure in the workplace? Yes No Within reasonable medical probability, is plaintiff's hearing loss related to repetitive exposure to hazardous noise over an extended period of employment? Yes No Within reasonable medical probability, is plaintiff's hearing loss due to a single incident of trauma? Yes No IMPAIRMENT Using the most recent AMA Guides to the Evaluation of Permanent Impairment, the plaintiff's permanent whole person functional impairment is %. Do not include any impairment ratings for tinnitus. The above impairment was calculated as follows: Chapter Table

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b. c. 3. 4. Does plaintiff have a total loss of hearing? Yes No Was any portion of plaintiff's hearing loss an active impairment prior to acquiring the work-related condition? Yes No A. B. J. 1. For affirmative answer, specify condition producing active impairment. ____________________ _____________________________________________________________________________ For affirmative answer, specify percentage of impairment due to the prior active condition. ___% RESTRICTIONS The plaintiff described the physical and hearing requirements of the type of work performed at the time of injury as follows:

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Which restrictions (if any) should be placed upon work activities due to the hearing loss?

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RECOMMENDATIONS FOR TREATMENT

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CERTIFICATION and QUALIFICATIONS of PHYSICIAN

I hereby certify that the above information is correct and that all opinions were formulated within the realm of reasonable medical probability. A copy of my curriculum vitae is attached if I have not obtained an Department of Workers Claims Physician Index Number.

Date: ____________________

________________________________________ Full name of Physician

_________________ Department of Workers Claims Physician Index No.

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Instructions for Completion of Form 107-I, 107-P, 108-OD, 108-CWP and 108-HL
The medical report forms of the Department 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. 2. All information must be typed or neatly printed. The Department 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, Department of Workers Claims, 657 Chamberlin Avenue, Frankfort, Kentucky 40601. 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. Height of a patient should be measured in centimeters and without shoes. If the patient's height is an odd number of centimeters, the next highest even height in centimeters shall be used. Objective medical findings to support a medical diagnosis means information gained through direct observation and testing of the patients, applying objective or standardized methods. KRS 342.0011(33). 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). Preexisting 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).

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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

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