COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : P. O. Box 8888, San Francisco, CA 94128 (800) 794-6900 Calendar No. Department of Industrial Relations, Industrial Medical Council State of California Index No. TREATING PHYSICIAN’S DETERMINATION OF MEDICAL ISSUES : JUDICIAL SUBPOENA Plaintiff(s) (The use of this form is optional. You may use it for interim/supplemental reports, at the completion of treatment, patient’s discharge or when patient becomes permanent and stationary to address relevant issues. Read the affirmation and sign page 2. Attach additional pages if necessary.) -against- : Employee: 2. Claim Number: 1. (Last Name) (First Name) 3. Social Security Number: : (M.I.) 4. Date of Birth: (For record keeping purposes only) 6. Occupation Title: 5. Date of Injury(ies): mm/dd/yy : 7. Date of This Exam Defendant(s) : mm/dd/yy ..... .. ........... .. 9. Employer:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10..Insurer/Claims .Administrator: Consult Necessary? Yes 11. Current Diagnosis No Referral Necessary? Yes mm/dd/yy 8. Date of Next Exam mm/dd/yy Primary Treating Physician (name): No Use ICD-9 Codes or DSM-IV (Also state diagnosis in lay terms if possible) THE PEOPLE OF THE STATE OF NEW YORK Primary: Other: TO PATIENT STATUS 12. Since the last exam, the patient’s condition has: (Check applicable boxes) improved as expected GREETINGS: improved , but more slowly than expected now been determined to be non-work related not improved significantly plateaued, no further improvement is expected worsened Check only if patient has been WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before discharged from care on 13. Patient has been complying with treatment regimen: the Honorable at the YES CourtNO mm/dd/yy , 14. Objective or Clinical Findings: located at County of Give all significant physical or on the in room , psychological day of , 20 , at o'clock in the noon, and at any recessed examination, testing, laboratory, imaging or or adjourned date, applicable and give evidence as a witness in this action on the part of the to testify diagnostic findings including measurements. (Use glossary of activity terms as applicable) 15. Subjective Findings: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to issued for a maximum penalty of $50 and all damages sustained as a Describe the complaints in the patient’s own the party on whose behalf this subpoena was words. Then, using the standard terminology result of your failure to comply. (listed in instructions under terms that describe intensity of pain) separately describe the subjective findings and list any aggravating or Witness, Honorable mitigating factors. Also, list relevant prior Court in day of injuries/impairments/disabilities. County, , one of the Justices of the , 20 16. History of Injury/Changes in condition (Attorney must sign above and type name below) WORK STATUS 17. The patient has been instructed to: Attorney(s) for remain off the rest of this day and return to work Estimated date patient can return to work with no limitations with limitations of mm/dd/yy Office and P.O. Address now return to work Date returning to work mm/dd/yy with no limitations Telephone No.: Facsimile No.: E-Mail patient can Estimated date Address: return to work Mobile Tel. No.: with limitations of remain off work and continue treatment IMC FORM 81556 (4/95) -1- mm/dd/yy American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : TREATMENT Index No. : Calendar No. : JUDICIAL SUBPOENA 18. Treatment Plan (complete all that apply) has not changed from last report estimated date of completion of treatment -againstmm/dd/yy Plaintiff(s) : current Medication: Type: : Frequency: current Physical Medicine/Therapy: : Duration: Attach. and.briefly .describe . . . new . . . . . for: . . . . . . . . . . . . . . . any . . . reports . . . Defendant(s) : ...................... Diagnostic Studies: Hospitalization/Surgery: Consultation/Other THE STATE OF NEW YORK THE PEOPLE OFServices: 19. Comments: (Note any changes in TO treatment plan) PERMANENT DISABILITY STATUS 20. Patient is: discharged, pre-injury status achieved (Do not prepare narrative report unless requested). GREETINGS: (Check applicable boxes) permanent & stationary (maximum medical improvement) (see box at bottom of this page). permanently that all from engaging excuses being customary you and each RU-90). WE COMMAND YOU,precluded business andin his/her usual andlaid aside,occupation (attachof you attend before , the Honorable Court I am unable to determine patient’s at the permanent disability status at this time. located at County of AFFIRMATIONS in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify Any parties assisting in witness in this action on the part of the I personally prepared this report. and give evidence as athe records review, evaluation or testing procedures are listed in the attachment to this report. I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best Your failure except as to information that I have punishable as a contempt of court and will make you penalty of my knowledge and belief, to comply with this subpoena is received from others. As to that information, I declare under liable to the party the information accurately describes the issued for provided to me and, except as and in damages sustained as of perjury that on whose behalf this subpoena was information a maximum penalty of $50noted allthis report, that I believe ita to be true. ofhave not violated comply. Section 139.3, and the contents of this report and bill are true and correct to the best of my result I your failure to Labor Code knowledge. Witness, Honorable The foregoing declaration was signed in Court in County, , one California, on County, of the Justices of the day of mm/dd/yy , 20 Signature License No Specialty (if any) Name (typed or printed) LAST (Attorney must sign above and type name below) M.I. FIRST ( Address: (Street or P. O. Box) City Zip ) Telephone Number Attorney(s) for Note to physician: If this is a final report, you are required to serve this report on the claims administrator and patient/patient’s attorney. IF THIS IS A FINAL REPORT AND THE PATIENT HAS NOT ACHIEVED PRE-INJURY STATUS, THE FOLLOWING ISSUES, IF RELEVANT, SHOULD BE ADDRESSED IN NARRATIVE FORMAT. THIS Office and P.O. Address RATE YOUR PATIENT’S REPORT WILL BE USED TO DISABILITY. YOUR OPINIONS CARRY GREAT WEIGHT. YOU MUST DESCRIBE THE BASIS FOR YOUR CONCLUSIONS IN YOUR REPORT. YOU MUST ALSO PROVIDE A LISTING OF ALL INFORMATION RECEIVED FROM THE PARTIES, REVIEWED IN PREPARATION OF THE REPORT OR RELIED UPON FOR THE FORMULATION OF YOUR OPINION. IF THE INJURY IS Telephone No.: ALLEGED TO BE A PSYCHIATRIC INJURY, A DETERMINATION OF THE PERCENT OF THE TOTAL CAUSATION RESULTING Facsimile No.: FROM ACTUAL EVENTS OF EMPLOYMENT IS REQUIRED. SEE ATTACHED GLOSSARY OF ACTIVITY TERMS AND TERMS THAT DESCRIBE INTENSITY OF PAIN AND FREQUENCY OF SYMPTOMS. E-Mail Address: Mobile Tel. No.: -2- American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : ISSUES WHICH SHOULD BE ADDRESSED, IF RELEVANT, IN NARRATIVE REPORT Calendar No. : History of the Injury or Illness. Outline the specific details of the injury or illness. Describe the course(s) of treatment, diagnostic JUDICIAL SUBPOENA Plaintiff(s) procedure performed and give names of any other treating or consulting physicians. -against- : General Medical History. Describe any previous, current or subsequent medical information relevant to this injury or illness. : Occupational History. Description of present and prior occupational duties. List source of description of duties. Where possible, use RU91, DEU 100’s job Analysis or you may use the Occupational History Form from the Physician’s Guide. : Defendant(s) Present Complaints. Describe in the patient’s words and also report using the appropriate medical terminology. : ...................................................... Examination Findings. Use objective measurements where appropriate. Give all significant physical or psychological examination, testing, laboratory, imaging, or diagnostic findings. THE PEOPLE OF Where possible, use ICD-9 codes Diagnostic Impression. THE STATE OF NEW YORKor terminology and criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Revised. TO Permanent Disability. Describe in appropriate terminology from the instructions your evaluation of the subjective and objective findings that describe both the intensity and frequency of the symptoms. Give measurements or objective factors if relevant. Describe any reduction of pre-injury work capacity, citing documentation or source of pre-injury capacity. GREETINGS: Work Limitations. Describe any limitations to all activities listed in the instructions. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Causation. Describe how the permanent disability is related at the patient’s occupation and the specific injury or cumulative to the the Honorable Court events causing this illness. You may refer to the Physician’s Guide for discussions. located at County of in room , the permanent disability arose or has arisen from other factors, (i.e. other injuries, underlyingany recessed day of , 20 , at o'clock in the noon, and at medical Apportionment. If any ofon the or adjourned date,apportionment between the disabilitywitness in thisthis injury and any previous or subsequent disability. to testify and give evidence as a resulting from action on the part of the condition) describe the You may refer to the Physician’s Guide for discussions. Medical Care. Describe any need for ongoing or future medical care as it relates to the industrial injury. Be as specific as possible Your failure to comply that this subpoena needed in the as a contempt of court and will make you liable to regarding the type and frequency of carewith will probably be is punishablefuture. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Vocational Rehabilitation. Is the patient able to continue doing the type of work in which he/she was engaged at the time of injury/ illness? If not, what specific modifications would be medically appropriate? What work restrictions or limitations are appropriate? (This should be consistent with work limitations above). Indicate what source you used , one of the Justices of the patient’s job to describe the duties of the Witness, Honorable at the time of injury. (This should be consistent with occupational listing above). Court in County, day of , 20 Psychiatric Protocols. If psychiatric disability exists, please refer to the psychiatric protocols established by the Industrial Medical Council. (8CCR § 43) (Copies are available at (800) 794-6900). (Attorney must sign above and type name below) Affirmations. The affirmations on page 2 must be included in any additional final narrative report in which the patient has not achieved pre-injury status. Attorney(s) for Except as prohibited by Labor Code section 139.3, a primary treating physician may designate another physician who is licensed in California to prepare the final report. You need not file or serve this page or the instruction page with the Treating Physician’s Determination of Medical Issues form. If you are not familiar with the terminology or reporting requirements for disability Office and P.O. Address evaluations, you may refer to discussions in the “Physician’s Guide” or the “Treating Physician’s Alert” available from the IMC. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com , COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : INSTRUCTIONS Index No. : GLOSSARY OF ACTIVITY TERMS Calendar No. Balancing : Maintaining body equilibrium to prevent falling when walking,: standing, crouching, or running on narrow, slippery, JUDICIAL SUBPOENA Plaintiff(s) or erratically moving surfaces; or maintaining body equilibrium when performing gymnastic feats. Bending : Angulation from neutral-straight position about joint (e.g.-elbow) or spine (forward or lateral spine flexion). Carrying : Transporting an object, usually holding it in the hands or arms, or on the shoulder. Climbing : Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands or arms. For climbing, the emphasis is placed upon body agility; for balancing, it is placed upon equilibrium. Defendant(s) -against- : : : : ...................................................... Crawling : Moving about on hands and knees or hands and feet. Crouching : Bending body downward and forward by bending legs and spine. THE PEOPLE OF THE STATE OF NEW YORK Feeling TO : Perceiving attributes of objects such as size, shape, temperature, or texture by means of receptors in skin particularly those of finger tips. Fingering : Picking, pinching, or otherwise working with fingers primarily (rather than with whole hand or arm as in handling). Handling : Seizing, holding, grasping, turning or otherwise working with hand or hands (fingering not involved). Kneeling : Bending legs at knees to come to rest on knee or knees. Pulling : Exerting force upon an object so that the object movers toward the force (includes jerking). GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable or lowering an object from one level to another (includes upward pulling). at the Court Lifting : Raising located at County of in room: Exerting force the an object of that the object 20 , on upon day so , moves away from the force (includes slapping, striking,any recessed , at o'clock in the noon, and at kicking, and Pushing or adjourned date, to testify and give evidence as a witness in this action on the part of the treadle actions). : Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Extending the arm(s) in any direction. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Sitting : Remaining to comply. result of your failurein the normal seated position. Reaching Standing : Remaining on one’s feet in an upright position at a work station without moving about. Witness, Honorable Court : , 20 Stooping in Bending bodyCounty, andday of by bending spine and waist. downward forward , one of the Justices of the TERMS THAT DESCRIBE INTENSITY OF PAIN A SEVERE pain would preclude the activity precipitating the pain. (Attorney must sign above and type name below) A MODERATE pain could be tolerated, but would cause marked handicap in the performance of the activity precipitating the pain. A SLIGHT pain could be tolerated, but would cause some handicap in the performance of the activity precipitating the pain. Attorney(s) for A MINIMAL (mild) pain would constitute an annoyance, but would cause no handicap in the performance of the particular activity (and would be considered a nonratable permanent disability). TERMS THAT DESCRIBE FREQUENCY OF OCCURENCE OF SYMPTOMS Office and P.O. Address Occasional means approximately 25% of the time. Intermittent means approximately 50% of the time. Frequent means approximately 75% of the time. Constant means approximately 90-100% of the time. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com