BI-205 01/06 Return completed form to: Physician’s Report of Occupational Pneumoconiosis BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 Claimant’s Name (First, Middle, Last) BrickStreet Use Only Claimant’s Address Silicosis City, State, Zip OP Date of Birth (Month, Day, Year) Male Female Date of first treatment or examination (Month, Day, Year) Single Married Widowed Diagnosis In your opinion has claimant contracted occupational pneumoconiosis? Social Security Number Yes OD No How long has claimant been suffering from the disease of occupational pneumoconiosis? Has the claimant’s capacity for work been impaired by occupational pneumoconiosis? Yes No If yes, to what extent? History: Has the claimant ever had Yes Pneumonia No Date Yes No Date Angina Pectoria Pleurisy Coronary Occlusion Asthma Rheumatic Heart Disease Tuberculosis Congestive Heart Failure Arthritis Other serious illnesses Surgery Accidents Yes Yes Yes No No Date and describe Date and describe No Date and describe Present complaints and duration of complaints Has the sputum of the claimant been examined for tubercle bacillus? Yes No If yes, by whom? What lab? Findings? Where are the lab reports filed? If employee is deceased, was an autopsy performed? Yes No Has claimant participated in any OP treatment program? Yes No American LegalNet, Inc. www.USCourtForms.com Have x-rays been made of the claimant’s lungs? Right lung Yes Yes No No Left Lung Hospital or Doctor Yes No If yes to either, please answer below. Date Where Filed Have pulmonary function studies, blood gas studies or other pertinent clinical examinations been performed? Hospital or Doctor Appearance: Good Date Fair Height: lbs. Breath Sounds: Normal No If yes, please answer below. Where Filed Findings Poor ft. Weight: Yes Findings in. One year ago: Suppressed Rales lbs. Wheezing Findings: Heart: Blood Pressure: Pulse: Sounds: Normal Abnormal Murmurs: Findings: Other significant physical abnormalities: Signature Address Date BrickStreet Mutual Insurance  P.O. Box 3151  Charleston, WV  25332-3151 American LegalNet, Inc. www.USCourtForms.com