History and Comments:
Please provide your diagnosis.
Please indicate the objective findings that support this diagnosis.
Please note any pre-existing conditions.
Is the above diagnosis directly related to the incident in question?
If not directly related, is the diagnosis related to the incident by aggravation, acceleration and precipitation of a pre-existing condition beyond normal progression?
If the diagnosis is related to the incident in question by aggravation, acceleration and precipitation of a pre-existing condition, is the aggravation temporary or permanent? Please explain.
Was an appreciable period of workplace exposure the sole cause of the condition or at least a material contributory causative factor in the conditions onset or progression?
Is the diagnosis a mere manifestation of a pre-existing deteriorating or degenerative condition unrelated to the incident/exposure in question?
Has all medical treatment to date been reasonable, necessary and related to the incident/exposure in question? If not, please explain.
Is further medical treatment needed to cure and relieve the effects of the incident/exposure in question? Please explain and be specific as to further recommended treatment to include type, frequency and duration of treatment.
Is the claimant able to return to work? If so, as of what date?
If the claimant is able to return to work, can he/she return to work with or without restrictions?
If work restrictions are required, please provide a summary of the restrictions you recommend to include the specific restrictions and duration of the specific restrictions.
Please indicate your medical opinion as to whether any permanent restrictions are required.
Please indicate your medical opinion as to whether these restrictions, either temporary or permanent, are related to the incident/exposure in question.
Has a healing plateau been reached as related to the incident/exposure in question? If so, please be specific as to the date the healing plateau was reached.
If a healing plateau has not been reached as related to the incident/exposure in question, please indicate your expert opinion as to when you feel healing plateau will be reached.
Has permanent partial disability been sustained as a result of the incident/exposure in question?
If so, please indicate the specific percentage of permanency sustained based on the appropriate guidelines.
