FORM 108 - CWP Medical Report – Occupational Disease Revised April 2005 KENTUCKY OFFICE OF WORKERS’ CLAIMS MEDICAL REPORT OF FILED: Do not write in this space DR. _________________________ A. 1. 2. 3. 4. 5. 6. 7. 8. 9. PLAINTIFF INFORMATION Plaintiff’s name: _________________________________________________________________ Address: _______________________________________________________________________ Social Security number: ___________________________________________________________ Date of birth: __________________________________________ Age: _____________________ Plaintiff height in centimeters: ______________________________________________________ Plaintiff’s job title and employer: ____________________________________________________ Date of examination(s): ___________________________________________________________ Purpose of examination: ο Treatment ο Evaluation requested by ________________________________ ο University evaluation Prior evaluation (if any) and date: ___________________________________________________ B. PLAINTIFF HISTORY Plaintiff related history of complaints allegedly due to coal workers’ pneumoconiosis as follows: (Include plaintiff’s smoking history, if any.) C. EMPLOYMENT HISTORY Employment History (Form 104) dated ________ is attached. Review form with plaintiff and list pertinent employment history, including history of exposure to coal dust in the severance and processing of coal. D. TREATMENT – Prior and Current Based upon a review of records and/or history related by plaintiff, treatment (including any periods of hospitalization) provided for the above complaints has been as follows: E. PHYSICAL EXAMINATION Results of physical examination including objective medical findings related to the occupational disease. American LegalNet, Inc. www.USCourtForms.com F. DIAGNOSTIC TESTING Check the applicable block for any testing reviewed and relied upon for medical conclusions. For pulmonary function testing, attach actual test results and tracings. Date Summary of Results ο Chest x-ray – Use ILO Classification and attach ILO Form ο Other x-rays reviewed of plaintiff and dates. Use ILO Classification and attach ILO Forms ο Pulmonary function testing pre-bronchodilator 1 2 3 Best % of Predicted 1 2 3 Best % of Predicted FVC FEV1 ο Pulmonary function testing post-bronchodilator, if indicated FVC FEV1 ο Other: G. DIAGNOSIS H. 1. CAUSATION Within reasonable medical probability, is plaintiff’s disease the result of exposure to coal dust in the severance or processing of coal? ο Yes ο No 2. Within reasonable medical probability, is any pulmonary impairment the result of exposure to coal dust in the severance or processing of coal? ο Yes ο No I. CERTIFICAITON and QUALIFICATIONS of PHYSICIAN I hereby certify that the above information is correct and that all opinions were formulated within the realm of reasonable medical probability. A copy of my curriculum vitae is attached if I have not obtained an Office of Workers Claims Physician Index Number. Date: ________________ ____________________________________ Full name of Physician ____________________ Office of Workers Claims Physician Index No. 108-CWP American LegalNet, Inc. www.USCourtForms.com