LB-0369 (REV 1/1) RDA 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM C-32 STANDARD FORM MEDICAL REPORT FOR INDUSTRIAL INJURIESdeposition and should bear the original signature of the physician making the report. STATE FILE # DATE OF INJURY DATE OF MMI PATIENT NAME SSN DATE OF FIRST EVALUATION DATE OF FINAL EVALUATION EMPLOYER Form completed by the: Evaluating Physician Treating PhysicianPLEASE PROVIDE A NARRATIVE SUMMARY OF THE COURSE OF TREATMENT WORK STATUS As a result of this injury, did you take the patient completely off work? Yes No , please provide the period(s) of time during which the patient was completely off work. As a result of this injury, did you recommend the patient return to work with restrictions? Yes No , please provide the period(s) of time during which the patient could return to work with restrictions. As a result of this injury, did you assign any permanent restrictions? Yes No If yes, please describe or attach those permanent restrictions: From To From To From To From To From To From To American LegalNet, Inc. www.FormsWorkFlow.com LB-0369 (REV 1/1) RDA 10183 PERMANENT IMPAIRMENT a.Date of MMI: b.Please attach a Final Medical ReportForm C-30A c.If you feel that the applicable edition of the AMA Guides does not adequately assess the medical impairment ofthe patient, please express an impairment that you think is appropriate and attach a detailed explanation of howyou arrived at the following percentage: % scheduled member % whole body CAUSATION For injuries occurring on or after July 1, 2014 only, your responses to the following questions must reflect your opinion to a reasonable degree of medical certainty, as opposed to speculation or possibility. In determining medical causation, you should consider all possible causes of the injury. The injury would be medically caused by employment if the employment activity, more likely than not, is primarily responsible for the injury or, primarily responsible for the need for treatment. What was the injury? What was the mechanism of injury? Was there a specific incident or series of incidents identified that brought about the injury? Yes No , please describe: Did the injury result in a need for treatment? Yes No Did the injury result in any disablement (time off work or restricted duty, temporary or permanent)? Yes No Was the employment activity, more likely than not, primarily responsible for the injury or primarily responsible for the need for treatment? Yes No An aggravation of pre-existing disease, condition or ailment may be medically caused by the employment activity if the employment activity is primarily responsible for advancing or making worse the pre-existing disease, condition or ailment. Further, the need for treatment is medically caused if the employment activity is primarily responsible for the need for treatment. Did this injury involve the aggravation of a pre-existing injury? Yes No , was the employment activity primarily responsible for advancing or making worse the pre-existing disease, condition or ailment? Yes No Was the employment activity primarily responsible for the present need for treatment of the pre-existing disease, condition or ailment? Yes No American LegalNet, Inc. www.FormsWorkFlow.com LB-0369 (REV 1/1) RDA 10183 For injuries occurring prior to July 1, 2014 only, please answer the following question: From a medical standpoint, considering the nature of occupation and medical history along with the diagnosis and treatment, did this injury more probably than not arise out of the employment? Yes No PHYSICIAN CERTIFICATION AND QUALIFICATIONS I certify that the information furnished is correct and am aware that my signature attests to its accuracy. I further certify that all opinions are formulated within a reasonable degree of medical certainty. I further certify that my curriculum vitae (CV) is attached and that it is accurate. Physician Signature: Date: Please print full name of physician American LegalNet, Inc. www.FormsWorkFlow.com