Free Form 108-OD - Kentucky

FORM 108 ­ OD Medical Report ­ Occupational Disease Revised April 2005

FILED:

KENTUCKY DEPARTMENT OF WORKERS CLAIMS MEDICAL REPORT OF DR. __________________________
Do not write in this space

A. 1. 2. 3. 4. 5. 6. 7. 8.

PLAINTIFF INFORMATION Plaintiff's name: _________________________________________________________________ Address: _______________________________________________________________________ Social Security number: ___________________________________________________________ Date of birth: ___________________________________________________________________ Plaintiff height in centimeters: ______________________________________________________ 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: _____________________________________

9.

B. PLAINTIFF HISTORY Plaintiff related history of complaints allegedly due to an occupational disease as follows: Note: If the occupational disease is lung or hear-related, include plaintiff's smoking history.

C. EMPLOYMENT HISTORY Employment History (Form 104) dated __________ is attached. Review form with plaintiff and list pertinent employment history.

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 related to the occupational disease. If the occupational disease is lung or heart-related, include all findings pertinent to the respiratory and cardiovascular systems.

F. DIAGNOSTIC TESTING Check the applicable block for any testing reviewed and relied upon for medical conclusions. Test X-rays CT Scan MRI Pulmonary Function Testing Other (specify) G. Date Personally Reviewed Yes Yes Yes Yes Yes No No No 1 No No FVC FEV1 2 3 Best % of predicted Summary of Results

DIAGNOSIS

H. 1.

CAUSATION Within reasonable medical probability, is plaintiff's disease or condition causally related to his/her work environment. Yes No Within reasonable medical probability, is any pulmonary impairment caused in part by factors in plaintiff's work environment (e.g., coal dust, chemicals)? Yes No Identify the relevant factors in the work environment and explain the causal relationship between the factors in the work environment and the above diagnosis.

2.

3.

108-OD

I. 1.

IMPAIRMENT Using the most recent AMA Guides to the Evaluation of Permanent Impairment, the plaintiff's whole body impairment is ________%. If the impairment is due to loss of pulmonary function, give class and percentage. Chapter and Tables utilized to arrive at impairment ratings. Chapter No. Table No. % Impairment of the Whole Person

2.

Body Part or System a. b. c. 3.

Plaintiff had a prior active impairment. Yes No a. For affirmative answer, specify condition producing active impair ment. _______________ _________________________________________________________________________ For affirmative answer, specify percentage of impairment due to the prior active condition. _________________________________________________________________________ RESTRICTIONS The plaintiff described the physical requirements of the type of work performed at the time of injury as follows:

b.

J. 1.

2.

Does the plaintiff retain the phys ical capacity to return to the type of work performed at the time of injury?

Yes No

3.

Which restrictions, if any, should be placed upon plaintiff's work activities as the result of the injury? CERTIFICATION and QUALIFICATIONS OF PHYSICIAN

K.

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. 108-OD