M-1 DIAGNOSTIC MEDICAL REPORT MAINE WORKERS' COMPENSATION BOARD EMPLOYEE NAME: EMPLOYEE SSN (last 4 digits only): XXX-XX- EMPLOYEE DOB: EMPLOYEE PHONE: EMPLOYER NAME: DATE OF INJURY: TIME OF INJURY: AM PM DID INJURY OCCUR ON EMPLOYER PREMISES? YES NO IF NO, LIST PLACE OF INJURY SUPERVISOR222S NAME SUPERVISOR222S PHONE: EMPLOYER FAX: NATURE/CAUSE OF INJURY: DATE OF THIS EXAMINATION : INITIAL PROGRESS FINAL ICD-9/10 DIAGNOSIS CODES: IN MY OPINION, WORK RELATED NOT WORK RELATED NOT YET IDENTIFIED AS TO CAUSE HAVE DIAGNOSTIC TESTS BEEN PERFORMED? YES NO, IF YES, LIST: IS TREATMENT TO CONTINUE? YES, IF YES, DATE TO BE SEEN AGAIN: NO, IF NO, PATIENT AT MMI? YES NO ESTIMATED LENGTH OF TREATMENT TREATMENT PLAN: OFFICE PROCEDURES: MEDICAL REFERRAL SPECIALTY: CONSULTANT: DOES TREATMENT INCLUDE MEDICATION THAT PREVENTS PATIENT FROM DRIVING OR PERFORMING SAFETY SENSITIVE WORK ? YES NO IF YES, LIST ALL MEDICATIONS: WORK CAPACITY: REGULAR DUTY NO WORK CAPACITY- IF CHECKED, ESTIMATED DATE OF RETURN : MODIFIED WORK (DESCRIBE RESTRICTIONS BELOW OR ON REVERSE) IF CHECKED, ESTIMATED LENGTH OF RESTRICTIONS? BODY REGION(S) THAT RESTRICTIONS APPLY TO: * : List Below OR See side 2 of form for detailed restrictions *Restrictions are provided at the professional recommendation of the medical provider. Actual functional testing may not have been performed to validate employee222s ability . American LegalNet, Inc. www.FormsWorkFlow.com GUIDELINES FOR COMPLETING THE M1 FORM ESTIMATED LENGTH OF TREATMENT: describe in days, weeks, or months TREATMENT PLAN: INCLUDE items like REST, MEDICATION, EXERCISE, or other forms of treatment OFFICE PROCEDURES: INCLUDE Items like CAST, SPLINT, STRAPPING, INJECTIONS, SUTURES, etc. MEDICAL REFERRALS: INCLUDE items like THERAPY, SURGEON, CHIROPRACTIC, etc. MODIFIED WORK: INDICATE RIGHT or LEFT as appropriate; FREQUENCY (Never, Occasional