Form 113b Revised 3/2010 SUMMARY OF MEDICAL RECORD ­ OCCUPATIONAL EXPOSURE (Please attach additional pages if necessary) Petitioner's Name: _____________________________ Date of Industrial Accident: _____________ Employer's Name: _____________________________ 1. Diagnosis What is your impression/diagnosis of the petitioner's medical problem(s)? __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 2. Causation/Aggravation Did the petitioner's occupational exposure during employment with the employer medically cause or aggravate the medical problem(s) described above? ___Yes ____No If the occupational exposure during employment with the employer caused an aggravation of petitioner's medical problem(s), is it a _____ temporary or ______ permanent aggravation? Is the sole cause of the petitioner's medical problem(s) described above due to the occupational exposure during employment with the employer? ___Yes ____No If no, please state separately and with specificity all other causes that have aggravated, prolonged, accelerated or in any way contributed to the petitioner's medical problem(s). __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ To what extent, by percentage, has another cause contributed to petitioner's medical problem(s)? __________________________________________________________________________________ 3. Work Release/Medical Stability Have you released the petitioner from work as the result of the medical problem(s) caused or aggravated by the occupational exposure during employment with the employer? ___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 problem(s) caused or aggravated by occupational exposure during employment with the employer? ___Yes ____No If yes, on what date and 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 problem(s) caused or aggravated by the occupational exposure during employment with the employer? ___Yes ____No American LegalNet, Inc. www.FormsWorkFlow.com Summary of Medical Record - Occupational Exposure Page 2 Petitioner's Name: _______________________________ 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 occupational exposure at issue.)? __________________________________________________________________________________ __________________________________________________________________________________ 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 petitioner's medical problem(s) caused or aggravated by occupational exposure during employment with the employer? __________________________________________________________________ Does the petitioner have medically prescribed permanent functional restrictions as the result of the occupational exposure during employment with the employer? ___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 problem(s) caused or aggravated by occupational exposure during employment with the employer? __________________________________________________________________________________ __________________________________________________________________________________ What necessary medical treatment are you currently recommending to treat the petitioner's medical problem(s) caused or aggravated by occupational exposure during employment with the employer? __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 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