FUNCTIONAL PROGRESS FORM Department of Labor & Industries PO Box 44291 Olympia WA 98504-4291 Please return this form to L&I at the address above for state fund claims OR mail it directly to the self-insured company for self-insured claims. Though voluntary, the attending physician is s strongly encouraged to use this form to track the patient's progress over time. How can I help my patent regain function and return to work? 1. At each office visit, use this form to chart your patient's functional progress. 2. Speak with the employer (or potential employers) to explore light-duty and/or modified work. Remember $5,000 may be available for job modifications 3. Ask for help from the claim manager and/or nurse consultant (1-800-848-0811). 4. When your patient's progress has breached a plateau: Please consider a consult. Or, if you feel the patient has reached maximum medical improvement, please consider doing an impairment rating or ask the department to obtains an independent medical examination. 5. For more information, see pages 34-38 of the Attending Doctor's Handbook (available at 1-800-848-0811). Patient name Date of injury L&I Claim number Employer contact Phone Vocational Counselor Phone Claim manager Phone Nurse consultant at L&I Phone For what diagnosis (es) are you using opioids? Start date of treatment Graph 1: Pain Summary (When treating with opioids, this estimate is the answer to question #1 in "Opioid Progress Report Supplement") 10 = Worst possible pain 10 8 6 4 2 0 = No pain 0 PLACE DATE OF OFFICE VISIT ON SLANTED LINES 10 = Level of Function prior to injury 10 8 5 = Partially recovered function since injury 0 = Severe impact on function at home or work. 6 4 2 0 Graph 2: Functional Progress Summary (When treating with opioids, this estimate is the answer to question F245-363-000 functional progress 12-2005 #6b in "Opioid Progress Report Supplement") American LegalNet, Inc. www.USCourtForms.com