BI-232 01/06 Return completed form to: Controlled Substance Report BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 1. What diagnosis is responsible for the claimant’s pain: Date: Claimant Name: Claim Number: 2. Body Part: Claimant SSN: Date of Injury: Vendor Number: 3. Is the claimant’s pain: Acute Chronic Intractable Psychogenic Nuerogenic Physician Numb er: Physician’s Name and Address: 4. Does the claimant have a history of drug or alcohol abuse? Yes No If yes, please explain: 5. Does the claimant have a chronic illness or disease not related to the compensable injury that could be responsible for the chronic pain? Yes No If yes, please explain: 6. Are there any medical conditions not related to the compensable injury that may require further treatment? Yes No If yes, briefly explain: 7. Are there any psychological factors to consider? Yes No If yes, briefly explain: 8. Was there a psychological condition prior to this injury? Yes No If yes, briefly explain: 9. Is there a detailed history of the pain phenomena? Onset: Duration: Yes No If yes, please complete the following: Radiation: Location: Level of pain using scale (Pre Analgesia) Severity: Level of pain using scale (Post Analgesia) Treatment of activities other than medications that relieve pain: 10. The following medications and / or treatment / therapies have been 11. Have you made an attempt to decrease the opioid dosage? prescribed: Nsaids Improved Not Improved If yes, when and at what intervals? Muscle Relaxants Improved Not Improved Steroids Improved Not Improved Opioids Improved Not Improved If no, why? Physical Medicine Improved Not Improved Injections Improved Not Improved 12. On what objective findings do you base the need for continued opioid therapy? 13. Have you referred the claimant for any consultations with other healthcare providers? If yes, with whom? Specialty Yes Yes No No Recommendations 14. Have you discussed with the claimant the risks and side effects involved in long -term opioid therapy? Yes No Do you have a signed statement from the claimant showing his / her understanding? Yes No If yes, please enclose a copy. 15. How do you rate the claimant’s potential to return to his / her pre -injury employment position? 16. Have you performed any random testing to ensure that the claimant is taking the opioid as prescribed? Yes No What were the results? Excellent Good Fair Poor 17. Does the claimant’s pain inhibit or interfere with his / her ability to perform ADL’s? Yes No If yes, please describe his / her limitations: I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware of the law, specifically § 61 -3-24G, provides for severe penalties if I knowingly certify a false report or statement, withhold material facts of statements or knowingly aid or abet anyone attempting to secure benefits to which he or she is not entitled. In signing this form, I acknowledge my contractual obligations to BrickStreet Insurance and agree to release any office no tes and test results immediately to BrickStreet Insurance. Comments: Physician Signature: Date: / / BrickStreet Mutual Insurance  P.O. Box 3151  Charleston, WV  25332-3151 American LegalNet, Inc. www.USCourtForms.com