FORM 108 – OD Medical Report – Occupational Disease Revised April 2005 FILED: KENTUCKY OFFICE OF WORKERS CLAIMS MEDICAL REPORT OF 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: ___________________________________________________________________ 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 by this physician (if any) and date: _____________________________________ B. PLAINTIFF HISTORY Plaintiff related history of complaints allegedly due to an occupational disease as follows: Note: If the occupational disease is lung or hear-related, include plaintiff’s smoking history. C. EMPLOYMENT HISTORY Employment History (Form 104) dated __________ is attached. Review form with plaintiff and list pertinent employment history. 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: American LegalNet, Inc. www.USCourtForms.com E. PHYSICAL EXAMINATION Results of physical examination, including objective medical findings related to the occupational disease. If the occupational disease is lung or heart-related, include all findings pertinent to the respiratory and cardiovascular systems. F. DIAGNOSTIC TESTING Check the applicable block for any testing reviewed and relied upon for medical conclusions. Test Date Personally Reviewed ο X-rays ο Yes ο No ο CT Scan ο Yes ο No ο MRI ο Yes Summary of Results ο No 1 ο Pulmonary Function Testing ο Yes ο No ο Other (specify) ο Yes 2 3 Best % of predicted ο No G. DIAGNOSIS H. FVC FEV1 CAUSATION 1. Within reasonable medical probability, is plaintiff’s disease or condition causally related to his/her work environment. ο Yes ο No 2. Within reasonable medical probability, is any pulmonary impairment caused in part by factors in plaintiff’s work environment (e.g., coal dust, chemicals)? ο Yes ο No 3. Identify the relevant factors in the work environment and explain the causal relationship between the factors in the work environment and the above diagnosis. 108-OD American LegalNet, Inc. www.USCourtForms.com I. IMPAIRMENT 1. Using the most recent AMA Guides to the Evaluation of Permanent Impairment, the plaintiff’s whole body impairment is ________%. If the impairment is due to loss of pulmonary function, give class and percentage. 2. Chapter and Tables utilized to arrive at impairment ratings. Body Part or System Chapter No. Table No. % Impairment of the Whole Person a. b. c. 3. Plaintiff had a prior active impairment. ο Yes ο No a. For affirmative answer, specify condition producing active impairment. _______________ _________________________________________________________________________ b. For affirmative answer, specify percentage of impairment due to the prior active condition. _________________________________________________________________________ J. RESTRICTIONS 1. The plaintiff described the physical requirements of the type of work performed at the time of injury as follows: 2. Does the plaintiff retain the physical capacity to return to the type of work performed at the time of injury? 3. K. οYes ο No Which restrictions, if any, should be placed upon plaintiff’s work activities as the result of the injury? CERTIFICATION 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 Cla ims Physician Index Number. Date: ____________ _________________________________ Full name of Physician ________________________ 108-OD American LegalNet, Inc. www.USCourtForms.com Office of Workers Claims Physician Index No. 108-OD American LegalNet, Inc. www.USCourtForms.com