"Attending Physician Statement - Rheumatology - Blue Cross" - Saskatchewan, Canada

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ATTENDING PHYSICIAN STATEMENT
Clear Form
Print
RHEUMATOLOGY
PO Box 4030 Saskatoon SK S7K 3T2
306.244.1192 Toll-free in Saskatchewan 1.800.667.6853
Fax 306.652.5751 www.sk.bluecross.ca
Instructions
1. Please print.
3. Part II–VI to be completed by physician.
2.
.
Part I to be completed by
patient.
4. Any fee for completing this form is the patient’s responsibility
PART I: PATIENT AUTHORIZATION
_________I_________ I________
Name _______________________________________________________________________ Date of Birth
Last
First
Initial
YYYY
MM
DD
I hereby authorize the release of any information herein requested by my insurer or its agent.
Signature __________________________________________________________________________ Date _______________________________
PART II: ATTENDING PHYSICIAN
Name ____________________________________________________________________ Specialty ____________________________________
Address _______________________________________________________________________________________________________________
Telephone _____________________________ Fax _______________________________ Email ______________________________________
Part III: HISTORY OF PRESENT CONDITION(S)
1.
Primary diagnosis ____________________________________________________________________________________________________
2.
Secondary diagnosis _________________________________________________________________________________________________
3.
Date symptoms first appeared
__ I_
_ I
___
4. Initial examination date
__ I_
_ I
___
YYYY
MM
DD
YYYY
MM
DD
5.
Date patient ceased working due to this condition ______ I_
_ I
___
YYYY
MM
DD
6.
RHEUMATOID ARTHRITIS
List joints involved ___________________________________________________________________________________________________
Is objective evidence of synovitis and joint deformity present?
Yes
No
Is contracture, ankylosis or impaired range of motion present?
Yes
No
If yes, describe ______________________________________________________________________________________________________
Laboratory findings
Positive synovial fluid findings ___________________________
A.N.A. _____________________________ Normal _____________
____________________________________________________
Rheumatoid factor titer ________________ Normal _____________
Histologic change from biopsy ___________________________
Sedimentation rate ___________________ Normal _____________
Other __________________________________________________________________________________________________________
Are X-ray findings characteristic of, or compatible with Rheumatoid Arthritis?
Yes
No
Results of medical or surgical treatment __________________________________________________________________________________
7.
OSTEOARTHRITIS
List joints involved ___________________________________________________________________________________________________
Is joint deformity and/or limitation of motion present?
Yes
No
If yes, describe _________________________________________
__________________________________________________________________________________________________________________
Are X-ray findings characteristic of, or compatible with degenerative joint disease?
Yes
No
Results of medical or surgical treatment __________________________________________________________________________________
8.
OTHER RHEUMATIC DISEASE
Reiter’s Syndrome
Ankylosing spondylitis
Connective tissue disorders ______________________________
Other __________________________________________________
Do X-ray findings confirm diagnosis?
Yes
No
If yes, describe _________________________________________________________
___________________________________________________________________________________________________________________
9.
FUNCTIONAL STATUS
Patient is able to
Frequency
Duration
Dominant hand (circle one)
LEFT
RIGHT
Sit
Can the patient use his/her hands and fingers for gross or
Stand
fine movements? Please specify.
Walk
Drive a car
Bend/twist
Squat/kneel/crouch
Climb stairs
Is the patient independent for activities of daily living, i.e.,
Reach above shoulder level
bathing, dressing, toileting, transferring, mobility, etc.?
Reach below shoulder level
Lift up to 10 lb / 5 kg
20 lb /10 kg
50 lb /25 kg
List any assistive devices or aids that would improve the patient’s ability to use his/her hands or to increase ability to sit, stand or walk
___________________________________________________________________________________________________________________
What reasonable job or work site modifications could the employer make to assist the patient in returning to work?
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
ATTENDING PHYSICIAN STATEMENT
Clear Form
Print
RHEUMATOLOGY
PO Box 4030 Saskatoon SK S7K 3T2
306.244.1192 Toll-free in Saskatchewan 1.800.667.6853
Fax 306.652.5751 www.sk.bluecross.ca
Instructions
1. Please print.
3. Part II–VI to be completed by physician.
2.
.
Part I to be completed by
patient.
4. Any fee for completing this form is the patient’s responsibility
PART I: PATIENT AUTHORIZATION
_________I_________ I________
Name _______________________________________________________________________ Date of Birth
Last
First
Initial
YYYY
MM
DD
I hereby authorize the release of any information herein requested by my insurer or its agent.
Signature __________________________________________________________________________ Date _______________________________
PART II: ATTENDING PHYSICIAN
Name ____________________________________________________________________ Specialty ____________________________________
Address _______________________________________________________________________________________________________________
Telephone _____________________________ Fax _______________________________ Email ______________________________________
Part III: HISTORY OF PRESENT CONDITION(S)
1.
Primary diagnosis ____________________________________________________________________________________________________
2.
Secondary diagnosis _________________________________________________________________________________________________
3.
Date symptoms first appeared
__ I_
_ I
___
4. Initial examination date
__ I_
_ I
___
YYYY
MM
DD
YYYY
MM
DD
5.
Date patient ceased working due to this condition ______ I_
_ I
___
YYYY
MM
DD
6.
RHEUMATOID ARTHRITIS
List joints involved ___________________________________________________________________________________________________
Is objective evidence of synovitis and joint deformity present?
Yes
No
Is contracture, ankylosis or impaired range of motion present?
Yes
No
If yes, describe ______________________________________________________________________________________________________
Laboratory findings
Positive synovial fluid findings ___________________________
A.N.A. _____________________________ Normal _____________
____________________________________________________
Rheumatoid factor titer ________________ Normal _____________
Histologic change from biopsy ___________________________
Sedimentation rate ___________________ Normal _____________
Other __________________________________________________________________________________________________________
Are X-ray findings characteristic of, or compatible with Rheumatoid Arthritis?
Yes
No
Results of medical or surgical treatment __________________________________________________________________________________
7.
OSTEOARTHRITIS
List joints involved ___________________________________________________________________________________________________
Is joint deformity and/or limitation of motion present?
Yes
No
If yes, describe _________________________________________
__________________________________________________________________________________________________________________
Are X-ray findings characteristic of, or compatible with degenerative joint disease?
Yes
No
Results of medical or surgical treatment __________________________________________________________________________________
8.
OTHER RHEUMATIC DISEASE
Reiter’s Syndrome
Ankylosing spondylitis
Connective tissue disorders ______________________________
Other __________________________________________________
Do X-ray findings confirm diagnosis?
Yes
No
If yes, describe _________________________________________________________
___________________________________________________________________________________________________________________
9.
FUNCTIONAL STATUS
Patient is able to
Frequency
Duration
Dominant hand (circle one)
LEFT
RIGHT
Sit
Can the patient use his/her hands and fingers for gross or
Stand
fine movements? Please specify.
Walk
Drive a car
Bend/twist
Squat/kneel/crouch
Climb stairs
Is the patient independent for activities of daily living, i.e.,
Reach above shoulder level
bathing, dressing, toileting, transferring, mobility, etc.?
Reach below shoulder level
Lift up to 10 lb / 5 kg
20 lb /10 kg
50 lb /25 kg
List any assistive devices or aids that would improve the patient’s ability to use his/her hands or to increase ability to sit, stand or walk
___________________________________________________________________________________________________________________
What reasonable job or work site modifications could the employer make to assist the patient in returning to work?
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Part IV: FACTORS AFFECTING RECOVERY
Current
height ________________ weight ________________
General fitness _______________________________________________________________________________________________________
Work environment _____________________________________________________________________________________________________
Home environment ____________________________________________________________________________________________________
Significant complaints out of proportion with clinical findings ____________________________________________________________________
____________________________________________________________________________________________________________________
Significant emotional or behavioural disorder, such as depression, addiction, etc. ___________________________________________________
____________________________________________________________________________________________________________________
Has the patient previously had a similar condition?
Yes
No If yes, specify date of initial onset _____________________________________
DATE (YYYY | MM | DD)
PART V: MANAGEMENT PLAN FOR THE CURRENT CONDITION
DATE (YYYY I MM I DD)
Frequency of visits ________________________________________________________________
I
I_
Date of most recent visit ____________________________________________________________
I
I_
Date of re-evaluation _______________________________________________________________
I
I_
Hospitalization dates - include admission/discharge summaries
___________________________________________________________________________________
I
I_
____________________________________________________________________________________
I
I_
_____________________________________________________________________________________
I
I_
_____________________________________________________________________________________
I
I_
Surgery date(s) and type(s) - include operative report(s)
_____________________________________________________________________________________
I
I_
_____________________________________________________________________________________
I
I_
_____________________________________________________________________________________
I
I_
Medication – include dosage
_____________________________________________________________________________________
I
I_
______________________________________________________________________________________
I
I_
______________________________________________________________________________________
I
I_
______________________________________________________________________________________
I
I_
Name of other healthcare providers
Specialty
Specialists ___________________________________ ____________________________________
I
I_
Counsellor ___________________________________ ____________________________________
I
I_
Therapist ____________________________________ ____________________________________
_
I
I_
Other _______________________________________ ____________________________________
I
I_
Is the patient following recommended treatment program?
Yes
No If no, explain circumstances ___________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
PART VI: ESTIMATED TIME FOR RECOVERY
1.
Patient progress
None
Regressed
Minimal Improvement
Significant Improvement
Plateaued
Resolved
Prognosis
Poor
Good
2.
In your opinion, is the patient a suitable candidate for a work re-entry program (i.e., ease-back, modified duties, gradual return to work, etc.)?
Yes
No
Provide comments and recommendations, including any restrictions with respect to return to work.
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
3.
Any additional information or details that may have a significant impact on the patient’s recovery from this condition?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
_____
Signature _____________________________________________________________________ Date ________________________________
® Saskatchewan Blue Cross is a registered trade-mark of the Canadian Association of Blue Cross Plans, used under license by Medical Services Incorporated, an independent licensee.
MSI 383 09/13
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