INDIANA WORKER'S COMPENSATION BOARD 402 West Washington Street, Room W196 Indianapolis, IN 46204-2753 REPORT OF ATTENDING PHYSICIAN State Form 2118 (R3 / 5-10) * This agency is requesting disclosure of your Social Security number in order to pursue its statutory responsibilities. Disclosure is voluntary and you will not be penalized for refusal. INSTRUCTIONS: This form may be used by the attending physician or independent medical examiner. PATIENT INFORMATION Social Security number * Age Name of injured employee Sex Male Female Address (number and street, city, state, and ZIP code) Name of employer Date of this report (month, day, year) Address (number and street, city, state, and ZIP code) ACCIDENT INFORMATION Date of injury (month, day, year) Time of injury / illness / exposure AM PM Date of disability (month, day, year) Describe accident / exposure INJURY INFORMATION State objective findings of injury / illness / exposure Is this the only cause of patient's condition? (If No, state contributing causes) Yes No Has normal recovery been delayed for any reason? (If Yes, please explain) Yes No ATTENDING PHYSICIAN TREATMENT Date of your first treatment (month, day, year) Who engaged your services? Describe treatment given by you Was patient treated by anyone else? (If Yes, by whom, give name) Yes Was patient hospitalized? Yes Date treated (month, day, year) No Name of hospital Date of admission (month, day, year) Date of discharge (month, day, year) No Is further treatment needed? (If Yes, please explain) Yes No Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com (This portion may be used by attending physician and/or independent medical examiner) (Check one) Patient was will be able to resume regular work on ___________________________ (month, day, year). was will be able to resume light duty work on _________________________ (month, day, year). Please explain any restrictions below. (Check one) Patient If there is permanent impairment as a result of this injury / illness / exposure, please give body part affected, degree of impairment and other pertinent information. (If there is an amputation to any of the fingers or thumb please indicate the point of amputation on the diagram below.) Remarks: (Use this section for an independent medical examination report or give any information of value not included above i.e. history, prognosis, or work restrictions of the patient.) Signature of physician Date (month, day, year) Telephone number ( ) Address of physician (number and street, city, state, and ZIP code) Is this report submitted as an independent medical examination? Yes Is further treatment necessary? (If necessary, please explain response in the remarks section above. Supplemental reports may be Yes submitted with this form.) Is course of medical treatment reasonable? (If necessary, please explain in remarks, section above.) Yes Signature of physician Date (month, day, year) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com No No No