State of California Additional pages attached PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT(PR-3) This form is required to be used for ratings prepared pursuant to the 1997 Permanent Disability Rating Schedule. It is designed to be used by the primary treating physician to report the initial evaluation of permanent disability to the claims administrator. It should be completed if the patient has residual effects from the injury or may require future medical care. In such cases, it should be completed once the patient's condition becomes permanent and stationary. This form should not be used by a Qualified Medical Evaluator (QME) or Agreed Medical Evaluator (AME) to report a medical-legal evaluation. Patient Patient last name: Patient Street Address/PO Box Occupation Patient first name: Patient City Date of Birth State Zip Code MI Sex Phone Number Claims Administrator Claims Administrator Name Claims Administrator Street Address Phone Number Claim number Claims Administrator City State Zip Code Employer Name Street Address Phone Number You must address each of the issues below. You may substitute or append a narrative report if you require additional space to adequately report on these issues. (For dates use mm/dd/yyyy.) Date of Injury Last Date Worked Date of Last Exam Date of Current Exam Permanent & Stationary Date City State Zip Code Description of how injury/illness occurred (e.g., Hand caught in punch press; fell from height onto back; exposed 25 years ago to asbestos): Patient's Complaints: DWC Form PR-3 (Rev. 10/2015) Sheet 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com State of California - Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-3) Relevant Medical History: Objective Findings: Physical Examination: (Describe all relevant findings; include any specific measurements indicating atrophy, range or motion, strength, etc.; include bilateral measurements - injured/uninjured - for upper and lower extremity injuries.) Diagnostic tests results (X-ray/Imaging/Laboratory/etc.): Diagnoses: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 Can this patient now return to his/her usual occupation? If not, can the patient perform another line of work? Yes Yes Sheet 2 of 6 No No Cannot Determine Cannot Determine DWC Form PR-3 (Rev. 10/2015) American LegalNet, Inc. www.FormsWorkFlow.com State of California - Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-3) Subjective Findings: Provide your professional assessment of the subjective factors of disability, based on your evaluation of the patient's complaints, your examination, and other findings. List specific symptoms (e.g., pain right wrist) and their frequency, severity, and/or precipitating activity using the following definitions: Severity: Minimal pain - an annoyance, causes no handicap in performance. Slight pain - tolerable, causes some handicap in performance of the activity precipitating pain. Moderate pain - tolerable, causes marked handicap in the performance of the activity precipitating pain. Severe pain - precludes performance of the activity precipitating pain. Frequency: Occasional - occurs roughly one fourth of the time. Intermittent - occurs roughly one half of the time. Frequent - occurs roughly three fourths of the time. Constant - occurs roughly 90 to 100% of the time. Precipitating activity: Description of precipitating activity gives a sense of how often a pain is felt and thus may be used with or without a frequency modifier. If pain is constant during the precipitating activity, then no frequency modifier should be used. For example, a finding of "moderate pain on heavy lifting" connotes that moderate pain is felt whenever heavy lifting occurs. In contrast, "intermittent moderate pain on heavy lifting" implies that moderate pain is only felt half the time when engaged in heavy lifting. Are there any activities at home or at work that the patient cannot do as well now as could be done prior to this injury or illness? Yes Pre-Injury Capacity: If yes, please describe pre-injury capacity and current capacity (e.g., used to regularly life a 30 lb. child, now can only lift 10 lbs.; could sit for 2 hours, now can only sit for 15 mins.) No Cannot Determine 1. 2. 3. 4. 5. 6. 7. 8. Are there any activities the patient cannot do? Yes Pre-Injury Capacity: If yes, please describe all preclusions or restrictions related to work activities (e.g., no lifting more than 10 lbs. above shoulders; must use splint; keyboard only 45 mins. per hour; must have sit/stand workstation; no repeated bending). Include restrictions which may not be relevant to current job but may affect future efforts to find work in the open labor market (e.g., include lifting restriction even if current job requires no lifting; include limits on repetitive hand movements even if current job requires none). No Cannot Determine 1. 2. 3. 4. 5. 6. DWC Form PR-3 (Rev. 10/2015) Sheet 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com State of California - Division of Workers' Compensation PRIMARY TREATING PHYSICIAN'S PERMANENT AND STATIONARY REPORT (PR-3) 7. 8. Medical Treatment: Describe any continuing medical treatment related to this injury that you believe must be provided to the patient. ("Continuing medical treatment" is defined as occurring or presently planned treatment.) Also, describe any medical treatment the patient may require in the future. ("Future medical treatment" is defined as treatment which is anticipated at some time in the future to cure or relieve the employee from the effects of the injury.) Include medications, surgery, physical medicine services, durable equipment, etc. Comments: Is the permanent disability directly cased by an injury or illness arising out of and in the scope of employment? (See next page for discussion of apportionment). Yes No Is the permanent disability caused, in whole or in part, by other factors besides this industrial injury or illness, including any prior industrial injury or illness? (See next page for discussion of apportionment). Yes No If the answer to the second question is "yes," provide below: (1) the approximate percentage of the permanent disability that is due to factors other than the injury or illness arising out of and in the course of employment; and (2) a complete narrative description of the b