BI- LBE 02/06 Return completed form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV, 25332-3151 Low Back Examination TO BE COMPLETED BY T HE PHYSICIAN. Patient name: SSN: Date of Injury: Date of Birth: Claim Number : Date of Exam: Physician: Address: HT. WT. Pulse BP Resp. Phone: FEIN: Please check one or more: Claim Reopening Impairment Rating 1. 120- day Examination Independent Examination Consultation Comprehensive Examination Inspection (standing) YES NO YES NO 1.1 Patient stands unassisted 1.2 Scoliosis 1.3 Antalgic lean(Asymmetry) 1.4 Lumbar Hypolordosis 1.5 Lumbar Hyperlordosis Other observations: 2. Palpation (standing, seating, or prone) 2.1 Vertebral tenderness/restriction L1 L2 L3 L4 L5 U S E B L AC K IN K 2.2 Coccyx tenderness (external palpation) 2.3 Sacral base & pelvis level (standing) Left YES Right NO YES NO 2.4 Paraspinal muscle tenderness 2.5 Paraspinal muscle spasm 2.6 Sacroiliac joint tenderness 3. Gait 3.1 Limp Yes No 3.2 Assistive devices (cane, brace, prosthesis) 3.3 Other observations Left Right Yes Explain: No RANGE OF MOTION CERTIFICATION 4. S quat 4.1 Squats fully and rises without difficulty Comments 5. Range of Motion (standing)* 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Sacral Flexion Sacral Extension Forward bending (Flexion) Backward bending (Extension) Right side bending Left side bending Comments 5.8 Inclinometer WNL Pain Restriction ° ° ° ° ° ° Yes No (Inclinometer required for impairment examinations) *NOTE: Subtract sacral motions from T12 motions (pp.3/126-129 AMA Guides, 4th ed.) Thoracolumbar motion testing is valid if the following four criteria are achieved. Please certify the status of the examinee on each of these four criteria: • The back injury is now stable. Yes No • The motions were not curtailed due to a report of pain, fear of injury, or neuromuscular inhibition. Yes No • Three consecutive measurements of each motion were within 5° (within 10° if the three averaged 50° or more) Yes No • Examinee passed validity test. Yes No Physician’s Signature Source: AMA Guides to the Evaluation of Permanent Impairment, pp. 112 & 127. BrickStreet Mutual Insurance  P.O. Box 3151  Charleston, WV  25332 American LegalNet, Inc. www.FormsWorkflow.com Patient’s Name Date of Exam Claim Number Page 2 6. MOTOR STRENGTH (standing, walking, seated, or supine) NORMAL ABNORMAL 6.1 Hip flexion 6.2 Hip extension 6.3 Hip abduction 6.4 Knee extension 6.5 Knee flexion 6.6 Ankle dorsiflexion 6.7 Ankle plantar flexion 6.8 Great toe extension 6.9 Heel toe walk 6.0 Toe walk 7. GRADE (OUT OF 5) LEFT RIGHT SENSORY (pin prick) (seated or supine) LEFT Normal RIGHT Diminished Absent Normal Diminished Absent 7.1 L3 sensory 7.2 L4 sensory 7.3 L5 sensory 7.4 S1 sensory 7.5 Comments 8. REFLEXES (seated) 8.1 Left +1 +2 +3 clonus 0 +1 +2 +3 clonus 8.3 Left 8.4 Right Achilles 0 8.2 Right USE BLACK INK Patellar (+2normal) 0 0 +1 +1 +2 +2 +3 +3 clonus clonus Other 9. STRAIGHT LEG RAISING (sitting) (0-90° scale) (Measure knee extension) 9.1 Left Pain: Yes No Location of Pain: Back Same Leg Contralateral back/leg 9.2 Right 10. ° ° Pain: Yes No Location of Pain: Back Same Leg Contralateral back/leg HIP AND SACROILIAC TESTS 10.1 Hip test pain 10.2 Sacroiliac test pain 11. Yes Yes No No Left Left Right Right STRAIGHT LEG RAISING (supine) (0 -90° scale) 11.1 Left ° Pain: Yes No Location of Pain: Back Same Leg Contralateral back/leg 11.2 Right ° Pain: Yes No Location of Pain: Back Same Leg Contralateral back/leg 12. PULSES 12.1 12.2 12.3 Left Right Dorsalis Pedis Present? Yes No Yes No Posterior tibial Present? Yes No Yes No Other observations (Clubbing, Cyanosis) __________________________________________________________ 13. MUSCLE MEASUREMENT 13.1 13.2 Left Thigh Left Calf Right Thigh Right Calf cm above patella cm below tibial tubercle 14. LEG LENGTH EXAM 14.1 Symmetrical 14.2 Shorter Difference of cm Yes Left Right No Right cm Not Tested Supine Left Standing cm Supine: measure from anterior superior iliac spine to medial/lateral malleolus. Standing: measure from greater trochanter to floor American LegalNet, Inc. www.FormsWorkflow.com Patient’s Name Date of Exam Claim Number Page 3 OTHER TESTS AND FINDINGS 16. CLINICAL IMPRESSION OF SOMATIC AMPLIFICATION SCORE SENSORY EXAMINATION: RESPONSE TO PINPRICK (check) 16.1 No deficit or deficit well localized to dermatome(s) Deficit related to dermatome(s) but some inconsistency Nondermatomal or very inconsistent deficit Blatantly impossible (i.e., split down midline of entire body with positive tuning fork test) 0 1 2 3 U SE BL A C K I N K 16.2 AMOUNT OF BODY INVOLVED 60% 3 Nonmyotomal or very inconsistent weakness, exhibits cogwheeling or giving away, weakness is coachable Blatantly impossible, significant weakness which disappears when distracted 16.3 AMOUNT OF BODY INVOLVED 60% 3 TENDERNESS 16.5 No tenderness or tenderness localized to anatomically sensible structure Tenderness not well localized, some inconsistency Diffuse or inconsistent tenderness, multiple structures (skin, muscle, bone, etc.) Impossible, significant tenderness of multiple structures (skin, muscle, bone, etc.) which disappears when distracted (check) (check) 0 1 2 3 (check) (check) 0 1 2 3 16.6 AMOUNT OF BODY INVOLVED (check) 60% 3 DIFFERENTIAL STRAIGHT LEG RAISING (SLR) 16.7 The difference between SLR tests performed in the supine and sitting positions (the patient is distracted in the sitting position by examining the bottom of his/her feet). Example: supine SLR positive at 10°, seated SLR positive 50°, difference = 40° Difference 45° 2 No pain seated, but strongly positive SLR when supine at less than 45° 3 TOTAL SCORE 17. C O M M E N T S American LegalNet, Inc. www.FormsWorkflow.com Patient’s Name Date of Exam Claim Number Page 4 18. RADIOGRAPHIC EXAM Yes No Date Type (Plain, CT, MRI, Myelogram) Findings(Attach report if available): Patient Position During X-ray: Recumbent Weight Bearing Unknown 19. CLINICAL DIAGNOSIS (Please indicate appropriate ICD-9 code(s) and give written description. Generic diagnoses are printed for your convenience; you may substitute other diagnoses. If appropriate, multiple diagnoses can be designated.) U SE B L A C K I N K SOFT TISSUE Lumbar sprain/strain (847.2) Lumbosacral sprain/strain (846.0) Sacroiliac sprain/strain (846.1) POSTERIOR JOINTS Facet syndrome (724.8) Lumbar subluxation (839.20) or segmented dysfunction (739.3) (circle) DISC Lumbar disc displacement without: myelopathy (with or without radiculitis) (722.10) Lumbosacral radiculitis (724.4) SACROILIAC Sacroiliitis (720.2) Sacroiliac subluxation(839.42) or segmental dysfunction(739.4)(circle) OTHER: 20. RECOMMENDATIONS, OPINION, REFERRALS, TX PLAN OR REDIRECTION: 21. AUTHORiZATION(S) REQUESTED FOR: 22. PHYSICIAN’S SIGNATURE DATE American LegalNet, Inc. www.FormsWorkflow.com Patient History – Back Pain Patient Name: SSN: Date of Injury: Date of Birth: Claim Number: Date of Exam: Physician must submit this form with low back exam. To be completed by physician’s staff. Physician: Address: Phone: FEIN: Page 5 P RE S E NT HI ST O RY PLEASE COMPLETE THE FORM IN BLACK INK. 7. Have you discussed your problem with your supervisor? 1. What are your problems? 8. 2. How did the problem occur? Yes No Is there modified or alternative work at your job? Yes No Don’t Know 8.1 Are you now working? Yes No 8.2 If yes, employer 8.3 If yes, your job title 9. 3. Where is the location of the problem/pain? Your pain is worse in your: Head Neck T O B E C O M PL ET E D B Y P AT I EN T ( A SS I ST A NC E P ER MI T T E D) Left Shoulder 4. Have you had this type of complaint before? Yes No When?/ Where? Right Shoulder Other: 10. Your problem/pain is: Left Arm Right Arm Right Hip Left Leg Back Right Leg Left Hip Better Worse No Different When you urinate or move your bowels When coughing or sneezing When you wake up in the morning 4.1 How did that earlier complaint occur? In the middle of the night Mid-day Evening Lying 5. What is the name of your employer? Sitting Driving 5.1 What is the type of business of that company? Bending Standing 5.2 What was your job title when problem began? Walking Change of position 11. Have you been treated for this complaint before now? Yes No Where? 12. What has helped this complaint the most? 13. What has helped or made this complaint worse? 14.1 Do you get pain at the tip of your tailbone? Yes 5.3 What was your usual job? (Job Tasks) 5.4 Describe your job tasks. No 14.2 Does your whole leg ever become painful? Yes 14.3 Does your whole leg ever go numb? Yes 14.4 Does your whole leg ever give way? Yes 14.5 In the past year, have you had any spells with very little pain? Yes No No No No 14.6 Have you had any intolerance to your treatment or reaction to treatment? Yes No 5.5 What job were you performing when problem began? 6. Who is you immediate supervisor? Name 14.7 Have you had an emergency room visit with back trouble since your recent work injury? Yes No Phone Number BrickStreet Mutual Insurance  P.O. Box 3151  Charleston, WV  25332 American LegalNet, Inc. www.FormsWorkflow.com Patient’s Name Date of Exam Claim Number Page 6 15. Have you ever had a spine X-ray, CT scan, MRI or myelogram? X-ray Yes No CT scan No When/Where/Results: Yes No When/Where/Results: 16. Have you ever been hospitalized for neck, arm, back, hip or leg complaints/pain? Yes No Which/When/Where 17. What other medical problems do you have? Phone No: Yes No 22. Do you smoke, rub, or chew tobacco? Yes No Yes List: No How Much? 23.1 Ever Have an alcohol problem? 24. Do you drink coffee or tea or caffeine drinks? How much per 24 hours? Yes No Yes No 25. How much formal education do you have? College or higher (specify): Heart, blood pressure, or circulation problems (circle) Vocational Training Diabetes Gout High School Diploma Arthritis Cancer GED Grade Completed: Other: PA S T H I ST O RY No 23. Do you drink beer, wine or liquor? No Myelogram Yes 21. Allergies to food, medicine or other? When/Where/Results: MRI Yes When/Where/Results: Yes 20. Do you have a family doctor? Name: Have you been hospitalized for any of the above problems? Yes No 26. Do you have other family members with serious back or neck problems? Yes No Are they disabled? Yes No 27. Any additional comments: Which/When: 19. What medicines are you now taking, including over-the-counter? Where is your pain? How does it feel? Draw your pain using the following key. Do not indicate areas of pain which are not related to your present injury or condition. D ra w i n y o u r f a c e : KEY: Back view Front View Stabbing / / / Burning X X X Pins and Needles OOO Aching, Throbbing ^^^ Numbness === Other • • • Signature of person completing form: Date: If signature is not of patient, then state relationship to patient: American LegalNet, Inc. www.FormsWorkflow.com