Physiotherapy initial assessment report (F-0006)

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Physiotherapy initial assessment report

Physiotherapy initial assessment report

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This information is being collected for the purpose of administering and enforcing the Workers’ Safety and Compensation Act in compliance with the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the board’s Privacy Officer at 401 Strickland St., Whitehorse, YT, Y1A 5N8 or call 867-667-5642 or 1-800-661-0443.

Worker Information

First Name

As shown on valid government-issued ID

Last Name

As shown on valid government-issued ID

Also known as

Street Number

Apartment Number/Unit Number

Street Name

City

Province/Territory

Postal Code

Country

Primary Phone Number

Work Phone Number

Date of Birth

Has the worker filed an application for compensation?

Yes No Unknown

Part of body affected (check all that apply)

Left Fingers

Left Hand

Left Wrist

Left Forearm

Left Elbow

Left Shoulder

Left Neck

Left Upper Back

Left Lower Back

Left Hip

Left Knee

Left Foot

Left Other

Right Fingers

Right Hand

Right Wrist

Right Forearm

Right Elbow

Right Shoulder

Right Neck

Right Upper Back

Right Lower Back

Right Hip

Right Knee

Right Foot

Right Other

Date of injury

Family doctor

if no family doctor please state none.

Employer

Heath care provider information

Clinic Name

Therapist Name

Street Number

Apartment Number/Unit Number

Street Name

City

Province/Territory

Country

Postal Code

I acknowledge that electronic communication has inherent security risks, as do all forms of communication. Notwithstanding the inherent risks of electronic communication, I consent to the use of electronic methods to transmit and receive information, including confidential and personal information between the board and myself. This consent will remain in effect until written notice to revoke this authorization has been received by the board

Primary Phone Number

Fax Number

Date of Visit

Subjective findings

Worker's description of injury

Has the worker had a similar problem in the past?

Yes No

Objective Findings

Observation findings

ROM and Biomechanical Analysis

Strength

Neurological

Special test and results


Test name	Result

none

Worker's current occupation

List the worker's five most critical job demands


Critical job demand	Current ability	Job match

Is the Job Demands Analysis for this occupation needed?

Yes No

Treatment plan


Treatment goals	Recommended treatment (Methodology)

Frequency and expected duration of treatment

Number of visits per week

Other

Duration

4 weeks

5 weeks

6 weeks

Other

Recommended or prescribed equipment or supplies

Return to work

Based on current functional abilities, can regular duties be performed?

Yes No

Are there barriers to recovery or return to work?

Yes No

Severe injuries with likely long term or permanent work restrictions

Has a Functional Abilities Form (FAF) been given to the worker?

Yes No

Additional comments

Signature, consent and declaration

By checking this box I declare that the information provided is true and correct. I consent to the release from any third party to Workers' Safety and Compensation Board (Board) of any medical, employment or other information relevant to my claim. I consent to the Board disclosing to health care providers, hospitals, physicians, my employers, other workers' compensation boards, and any other relevant third parties, all relevant information necessary to administer my claim in accordance with the law.

My name is

My email is

reCAPTCHA

FOR OFFICE USE ONLY

Initial Treatment Authorization

Workers name

Claim number

Case Manager

Phone number

Disability management guideline for injury

Injury

Length of Disability

Authorization

Initial assessment and 2 treatment sessions approved Treatment plan approved as recommended Treatment plan approved with modifications.

Explain

Estimated treatment plan end date (dd/mm/yyyy)

Treatment plan not approved Claim denied Call case manager to discuss

Next reporting due

Additional comments

Case manager signature

Date of approval (dd/mm/yyyy)