|
Diagnosis and Impairments
|
|
|
Affected Body Parts
|
|
|
Wrist/Hand
|
|
|
Range of Motion (Left/Right)
|
|
|
Flexion
|
UEI (%)
|
|
Extension
|
UEI (%)
|
|
Radial Deviation
|
UEI (%)
|
|
Ulnar Deviation
|
UEI (%)
|
|
Grip Strength
|
|
|
Average Grip Strength (Left)
|
Average Grip Strength (Right)
|
|
Strength Loss Index
|
UEI (%)
|
|
Surgical Procedure(s)
|
|
|
Surgical Procedure(s)
|
UEI (%)
|
|
Shoulder
|
|
|
Range of Motion (Left/Right)
|
|
|
Flexion
|
UEI (%)
|
|
Extension
|
UEI (%)
|
|
Adduction
|
UEI (%)
|
|
Abduction
|
UEI (%)
|
|
External rotation at 90
|
UEI (%)
|
|
Internal rotation at 90
|
UEI (%)
|
|
Grip Strength
|
|
|
Average Grip Strength (Left)
|
Average Grip Strength (Right)
|
|
Strength Loss Index
|
UEI (%)
|
|
Surgical Procedure(s)
|
|
|
Surgical Procedure(s)
|
UEI (%)
|
|
Elbow
|
|
|
Range of Motion (Left/Right)
|
|
|
Flexion
|
UEI (%)
|
|
Extension
|
UEI (%)
|
|
Pronation
|
UEI (%)
|
|
Supination
|
UEI (%)
|
|
Grip Strength
|
|
|
Average Grip Strength (Left)
|
Average Grip Strength (Right)
|
|
Strength Loss Index
|
UEI (%)
|
|
Surgical Procedure(s)
|
|
|
Surgical Procedure(s)
|
UEI (%)
|
|
Knee
|
|
|
Range of Motion (Left/Right)
|
|
|
Extension
|
LEI (%)
|
|
Flexion
|
LEI (%)
|
|
Atrophy (cm)
|
|
|
Quadriceps Atrophy
|
LEI (%)
|
|
Calf Atrophy
|
LEI (%)
|
|
Muscle Weakness (0-5)
|
|
|
Flexion
|
LEI (%)
|
|
Extension
|
LEI (%)
|
|
Surgical Procedure(s)
|
|
|
Surgical Procedure(s)
|
LEI (%)
|
|
X-Ray Cartilage Intervals
|
|
|
X-ray Cartilage Intervals
|
LEI (%)
|
|
Ankle
|
|
|
Range of Motion (Left/Right)
|
|
|
Dorsiflexion
|
LEI (%)
|
|
Plantarflexion
|
LEI (%)
|
|
Inversion
|
LEI (%)
|
|
Eversion
|
LEI (%)
|
|
Surgical Procedure(s)
|
|
|
Surgical Procedure(s)
|
LEI (%)
|
|
Additional Comments
|
|
|
Cervical Spine
|
|
|
Range of Motion
|
|
|
Flexion
|
WPI (%)
|
|
Extension
|
WPI (%)
|
|
Right Lateral Bend
|
WPI (%)
|
|
Left Lateral Bend
|
WPI (%)
|
|
Right Rotation
|
WPI (%)
|
|
Left Rotation
|
WPI (%)
|
|
Surgical Procedure(s)
|
|
|
Surgical Procedure(s)
|
UEI (%)
|
|
Lumbar Spine
|
|
|
Range of Motion
|
|
|
Flexion
|
WPI (%)
|
|
Extension
|
WPI (%)
|
|
Right Lateral Bend
|
WPI (%)
|
|
Left Lateral Bend
|
WPI (%)
|
|
Surgical Procedure(s)
|
|
|
Surgical Procedure(s)
|
LEI (%)
|
|
Total Impairment Values
|
|
|
Upper Extremity Impairment (%)
|
|
|
Lower Extremity Impairment (%)
|
|
|
Whole Person Impairment (%)
|
|
|
Current Subjective Factor of Impairment
|
|
|
Subjective Factors
|
|
|
Objective Factors of Impairment
|
|
|
Objective Factors
|
|
|
Work Restrictions
|
|
|
None
|
Work Restrictions - Free Text
|
|
Future Medical Care
|
|
|
All Future Care
|
Future Medical Care Free-Text
|
|
Vocational Rehabilitation
|
|
|
None
|
Vocational Rehabilitation
|
|
Apportionment
|
|
|
Percentage Work-Related
|
|
|
Causation
|
|
|
Directly Related to Work Injury
|
Causation Free Text
|
|
Reasons for Opinion
|
|
|
Reasons for Opinion
|
|
