Department of Industrial Relations, Industrial Medical Council, PO Box 420603, San Francisco, CA 94142 State of Tel (415) 737-2767 Treating Physician's Report California Patient 1. Patient Name (First, Middle, Last) 5. Address Employer 2. Social Sec No.: 3. Date of Injury: 4. Date of Exam No. and Street City Zip 6. Telephone No. and Street City Zip 9. Telephone 7. Name: 8. Address 10. The following medical issues will be used to determine the patient's eligibility for workers' compensation. Check the Medical appropriate box and reference the corresponding page(s) or section of the med-legal report for details. Issues And Report page(s) Pending or Conclusions or section Yes No Info. Not Sent a. Did work cause or contribute to the injury or illness? b. Are there pre-existing or other impairments/disabilities that contribute to permanent disability? c. Is there a need for current or future medical care? d. Is the medical condition stable and not likely to improve with active medical or surgical treatment (i.e., is the condition permanent and stationary)? e. Is there permanent impairment? f. Can this patient now return to their usual job? If yes: Yes No i. Without restrictions Yes No, If YES, Date: ii. With restrictions Yes No, If YES, Date: If restricted work is recommended, reference page(s)/section in report for details: Basis for Check box and refer to page(s) or section in report. Conclusions Report page(s) or section Yes Pending or Info. Not Sent No 11. Are there subjective complaints? 12. Are there any abnormal physical examination findings? 13. Are there any relevant diagnostic test results (x-ray/laboratory)? 14. What are the diagnoses? (List) 15. Were other physicians consulted? Treating 16. Signature Physician 17. Name 18. Address IMC-001 Rev. 11/30/93 Yes No Date: Specialty No. and Street City Cal. # Zip Tel. American LegalNet, Inc. www.USCourtForms.com Department of Industrial Relations, Industrial Medical Council, PO Box 420603, San Francisco, CA 94142 Tel (415) 737-2767 Instructions To the Treating Physician: Under Labor Code §4061.5, you are required by law to report the findings from your medical evaluation on the form prescribed by the Industrial Medical Council (IMC). Please complete the form in its entirety. Patient Information: Fill in patient's full name, address, telephone, date of injury, and date of examination. Exam Referral Schedule: Complete dates that patient called for an appointment, date of initial examination, and date referred for consultation(s), if any. Medical Issues and Conclusions: Complete this section by checking appropriate box and stating what page(s) or section of the medical legal report contain the narrative for details. If diagnostic or laboratory tests have been ordered and the results or a medical records request is pending, check that box. If you cannot render opinions because of pending information, please state what issues could not be evaluated. Basis for Conclusions: Check appropriate box and give page numbers or section where the narrative in the full report is found. For diagnoses, in addition to page numbers, please briefly summarize the diagnoses. Also, list name and specialty for other physicians who provided information used in the medical legal report. Signature: Under the Labor Code, all reports must be signed under the penalty of perjury. IMC-001 Rev.11/30/93 American LegalNet, Inc. www.USCourtForms.com