BI-231 01/06 Physical Medicine Follow-up Report Claimant Name: Claim Number: Claimant SSN: Date of Injury: Date: Vendor Number: Physician Number: Physician's Name and Address: Return completed form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 1. Date of this evaluation: 2. Please complete the chart below. Modality Frequency Duration Improved Modality Frequency Duration Improved Yes No E- Stim Yes No Passive ROM Yes No Chiropractic Manipulations Yes No Strengthening Yes No Osteopathic Manipulations Yes No Exercises Yes No Heat Yes No Aquatic Therapy Yes No Ice Yes No Massage Yes No lontophoresis Yes No Ultrasound COMPLETE THE FORM IN BLACK INK. Active ROM Yes No Phonophoresis Yes No TENS Yes No Traction Yes No Other Yes No Other Yes No 3. Active ROM "*You may obtain this Information from the physician or therapist providing the treatment** Body Part Flexion Extension Adduction IR ER Other Other ER Other Other 4. Passive ROM **You may obtain this information from the physician or therapist providing the treatment"* Body Part Flexion Extension Adduction IR 5. Manual Muscle Testing **You may obtain this information from the physician or therapist providing the treatment** Body Part Results 11. Grip Strength RT kg 12. Asymmetrical Reflexes RUE LUE LFT kg RLE LLE 13. What are your subjective and objective findings? Pain Edema Limited AROM Limited PROM Tenderness Other (explain) Effusion I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware that the law, specifically §61-3-24g, provides for severe penalties if I knowingly certify a false report or statement, withhold material fact or statement 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 notes and test results immediately to BrickStreet Insurance. PHYSICIAN SIGNATURE: DATE: BrickStreet Mutual Insurance  P.O. Box 3151  Charleston, WV  25332 American LegalNet, Inc. www.USCourtForms.com