Tangiers International | Adventist Claim Form

IME Doctor Details
Name and Surname of IME Doctor*
Medical Registration Number/License*
WORKER DETAILS
Date and place of examination*
Unusual circumstances*
Interpreter provided*
- Yes
- No
Name*
Claim number*
Date of injury*
Date of birth*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer at time of injury*
Date of examination*
Location of examination*
Examiner(s)*
Introduction*
History from worker
Chief complaints*
History of present injury*
Current symptoms*
Occupational history*
Current work status*
Past medical history
Injuries*
Illnesses*
Operations*
Hospitalizations*
Allergies*
Medications*
Tobacco*
- Yes
- No
Alcohol*
- Yes
- No
Illicit drugs*
- Yes
- No
Family history*
Marital/Family status and dependents*
Education*
Military*
Review of systems*
Record review*
PHYSICAL EXAMINATION
Height*
Weight*
Blood*
Pulse*
Pressure*
Temperature*
Dominant Hand*
Exam findings*
Diagnostic studies*
Pain status inventories*
CONCLUSIONS
Accepted conditions (as stated on the assignment letter from the claim manager)*
Diagnoses and assessment of work-relatedness
Diagnoses*
Pre-existing conditions*
Conditions acquired after the industrial injury or exposure*
Discussion and assessment of work-relatedness*
Prognosis*
Physical Restrictions*
Review of Job Analyses*
Recommendations
Diagnostic*
Therapeutic*
Follow-up care*
Findings unrelated to the accepted condition*
Impairment Rating Report
Maximum Medical Improvement*
Physical exam*
Diagnostic tests*
Rating*
Rationale*
Answers to specific questions from the claim manager*

ATTENDEES
List any other attendees at the examination (including family members / friends)*
SERVICE STANDARDS
The purpose of the examination*
Your role as an IME*
Your specialty and its relevance to the examination*
How the worker will be examined*
Did you answer all of the worker’s questions?*
- Yes
- No
Summary of reason for referral*
History relevant to injury*
Subsequent worker history*
Current complaints/symptoms*
Details of diagnostic investigations*
Treatment and medications*
Other relevant medical and occupational history*
Personal and social history*
Limitations on activities*
Past history*

DETAILS OF THE EXAMINATION
Clinical examination findings*
Mental state examination (when and where clinically indicated). List of all work-related injuries or illnesses assessed in examination.
Responses to specific questions*
All specific questions must be answered. Where there is potential duplication in a response to a specific question and a mandated template topic, the information or opinion need only be provided once.
Conclusions*
Summary of the worker’s condition. Relevance of current management plan for the worker’s work-related injury or illness with justification. Proposed management or changes to current management. Worker’s capacity to return to work. Functional capacity with evidence supporting any recommended restrictions.

SIGNATURE
Your report must be completed and provided to the requester of the report within 7 business days of the worker’s examination.
Name*
Specialty*
Today's date*
Signature*

Independent medical examination Form

IME Doctor Details

WORKER DETAILS

History from worker

Past medical history

PHYSICAL EXAMINATION

CONCLUSIONS

Recommendations

Impairment Rating Report

ATTENDEES

SERVICE STANDARDS

DETAILS OF THE EXAMINATION

SIGNATURE

Testimonials

Awards

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Independent medical examination Form

IME Doctor Details

WORKER DETAILS

History from worker

Past medical history

PHYSICAL EXAMINATION

CONCLUSIONS

Recommendations

Impairment Rating Report

ATTENDEES

SERVICE STANDARDS

DETAILS OF THE EXAMINATION

SIGNATURE

Testimonials

Awards

Subscribe to our mailing list

Navigation

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