Form 113a Revised 3/2010 SUMMARY OF MEDICAL RECORD ­ INDUSTRIAL ACCIDENT (Please attach additional pages if necessary) Petitioner's Name: _____________________________ Date of Industrial Accident: _____________ Employer's Name: _____________________________ 1. Diagnosis and Cause Please identify each and every medical problem caused petitioner by the industrial accident at issue. __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 2. Preexisting Causes Does the petitioner suffer from a pre-existing medical condition that contributed to the medical problems identified by you in your answer to question No. 1 as caused by the industrial accident at issue? ___Yes ____No If yes, please explain: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 3. Work Release/Medical Stability Have you released the petitioner from work as the result of the medical problems caused by the industrial accident at issue? ___Yes ____No If yes, on what date? __________________________ Have you released the petitioner to work with medically prescribed functional limitations ("light duty") as the result of the medical problems caused by industrial accident at issue? ___Yes ____No If yes, on what date? _____________________ If yes, describe in detail the functional limitations? __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Have you released the petitioner to return to work with no restrictions? ___Yes ____No If yes, on what date? ________________________________________________________________ Is the petitioner medically stable (stabilization means that the period of healing has ended and the condition of the petitioner will not materially improve) with respect to the medical problems caused by the industrial accident at issue? ___Yes ____No If yes, on what date (please identify separately a specific date of medical stability for each medical problem if more than one caused by the industrial accident at issue.) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Summary of Medical Record - Industrial Accident Page 2 Petitioner's Name: _________________________________ 4. Permanent Impairment If the petitioner is medically stable, what is the percentage of permanent impairment, based upon Utah Code §34A-2-412 or the American Medical Association's "Guides to the Evaluation of Permanent Impairment, Fifth Edition" as modified by "Utah's 2006 Impairment Guides," that is attributable to the medical problem caused by the industrial accident at issue? __________________________________ Does the petitioner have medically prescribed permanent functional restrictions as the result of the medical problem caused by the industrial accident at issue? ___Yes ____No If yes, please describe in detail: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 5. Medical Treatment. What treatment has been provided to date that was necessary to treat the petitioner's medical condition(s) caused by the industrial accident at issue? __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ What necessary medical treatment are you currently recommending to treat the petitioner's medical condition(s) caused by the industrial accident at issue? __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 6. Permanent Total Disability Cases. If you found that the petitioner is permanently and totally disabled, please describe in detail each and every medically prescribed functional restriction on petitioner's activities and the specific medical problem causing the restriction. __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Dated this ______ day of __________________, 20____. _______________________________________________ Physician's Name (please print) ________________________________________________ Physician's Signature ________________________________________________ Physician's City/State/Zip _________________________________________ Physician's Specialty _________________________________________ Physician's Street Address _________________________________________ Physician's Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com