1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 TELEPHONE 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com CHIROPRACTIC PROGRESS / FINAL REPORT CLAIMS DIVISION SFN 53147 (05/2008) PLEASE PRINT OR TYPE USING BLACK OR BLUE INK PLEASE COMPLETE AND RETURN THIS FORM PROMPTLY Claim Number Social Security Number Injury Date Birth Date Sex Female Male Area of Injury Injured Worker’s Name Employer Name Address Address City State Zip Code City State Zip Code PLEASE COMPLETE THIS SECTION IN FULL Date of examination on which report is based Will worker be seen again? Yes No Describe If yes, When? Any treatment since last report Yes No Was worker referred to a specialist? When Give name Yes No Has worker returned to work? If yes give date Yes No Was recovery complete, maximum medical improvement If yes, give date Date of discharge from care reached? Yes No If no, explain below Will any permanent impairment result? Yes No Unknown If there is permanent impairment, is it at least 16% whole body according to the current edition of AMA Guides to the Evaluation of Permanent Impairment? Yes No Describe completely the worker’s condition. (include any other pertinent information) Current Activity Restrictions: Diagnosis/Condition based upon objective medical findings: Diagnosis Code Doctor’s Name Federal Tax ID Address Telephone Number City State Doctor’s Signature Zip Code Date C25 American LegalNet, Inc. www.FormsWorkFlow.com