MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS PHYSICIAN'S REPORT ON EYE INJURIES 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 573-751-4231 www.labor.mo.gov/DWC NOTE: This report is required in each case of eye injury resulting in any degree of permanent disability so that a correct evaluation of the loss sustained may be made and the amount of compensation due for it accurately computed. State's Number For: Carrier's File No. File: Carrier: Employer: IN ORDER FOR THIS FORM TO SERVE ITS PURPOSE, ALL REQUESTED DATA MUST BE PROVIDED. Eye injuries not resulting in any permanent disability should be reported on the regular report form, Medical Treatment Form (WC-9). The Patient 1. Name of Injured Person 2. Address City 3. Name and Address of Employer Age Sex State The Accident 4. Date of Accident Hour a.m. p.m. Date disability began 5. State (in patient's own words) where and how accident occurred The Injury 6. Which eye was injured? 8. Nature of injury and diagnosis 7. Is other eye affected by injury? Yes No 9. Is condition of eye(s) not stationary? Yes No Yes No 10. Have all adequate and reasonable operations and treatment been attempted? If "No," explain: WC-241 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com I. CENTRAL VISUAL ACUITY READINGS Without Any Corrective Lenses With Correction Only for Natural Presbyopia and Other Conditions Clearly Not the Result of Injury Distance Near Distance 11. Right Eye 12. Left Eye Near II. FIELD OF VISION NOTE: The field of vision shall be determined on a standard perimeter using white test target of 1 degree. 13. Is there any loss of field of vision? Yes No 14. Is it a result of injury? Yes No If "Yes," show below by tracing the reduced field in outline on the applicable figure and by giving reading found at the eight principal meridians in the center box. III. BINOCULAR VISION NOTE: Test is to be made without corrective lenses or prisms. 15. Is there useful binocular vision? Yes No Yes No 16. Is there any diplopia (double vision) present? 17. If "Yes," plot on the accompanying chart by placing an "X" in each rectangle where diplopia is present. WC-241-2 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com IV. SECONDARY OCULAR DISABILITIES 18. If there are ocular disabilities other than those covered in the foregoing sections, please indicate them below by appropriate checking, and if any of the first three are checked indicate under "Remarks" your estimate of the percentage. If any secondary disability exists that is not listed, note it in the blank space provided. If there are no secondary disabilities, check this box A. Paralysis of Accommodation ................................ B. Ectropion ......... or Entropion .............. H. Eye Brow (Complete Loss of) Unilateral ..................................................................... Bilateral ....................................................................... I. Eye Lashes (Complete Loss of) Unilateral ..................................................................... Bilateral ....................................................................... J. Cataract (Traumatic) .................................................... K. Dislocation of Lens (Traumatic) Partial .......................................................................... Complete ..................................................................... L. Scotoma (Traumatic) ................................................... If NOT centrally located .............................................. M. __________________________________________ __________________________________________ __________________________________________ __________________________________________ Unilateral .............................................................. Bilateral ................................................................ C. Iridectomy (Traumatic or Surgical) Photophobia and Dazzling .................................... D. Lagophthalmos ..................................................... Unilateral .............................................................. Bilateral ................................................................ E. Epiphora Unilateral .............................................................. Bilateral ................................................................ F. Symblepharon (Also Limited Muscle Function) .. G. Ptosis Unilaterial ............................................................. Bilateral ................................................................ 19. REMARKS (over) WC-241-3 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com V. PRE-EXISTING SUBNORMAL VISION 20. Is there record of adequate and positive indication of pre-existing subnormal vision? If "Yes," explain: Yes No 21. Is there likelihood of further impairment of the pre-existing subnormal vision, as a result of this injury? If "Yes," explain: Yes No VI. CONDITIONS REQUIRING DELAYED FINAL EXAMINATION In cases of disturbance of extrinsic ocular muscles, optic nerve atrophy, retained intraocular foreign body, injury to the retina, sympathetic ophthalmia, and traumatic cataract, at least six months ­ preferably not more than from 12-16 months ­ must elapse before final examination shall be made on which this report is based. 22. If any of the conditions mentioned immediately above exist, is there likelihood of further impairment occurring as a result of the injury? Yes No If "Yes," explain: 23. Date of Examination 24. Doctor's Signature (Required in doctor's own handwriting) 25. Address City Date of Report State WC-241-4 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com