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Referral Date:

(mm/dd/yyyy)

Employer Information
*Company Name:
Address 1:
Address 2:
City:		Province:	ABBCMBNBNFNSNTNUONPEQCSKYT
Postal Code:
*Case Manager's First Name:		*Case Manager's Last Name:
*Telephone:		Cell or Other Phone:
Email:		Fax:
*Date of Disability Onset:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	*File/Reference Number:

Employee Information
*First Name:		*Last Name:
Gender:	Male Female	*Date of Birth:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Telephone:		Examinee Cell or Other Phone:

File Description

Diagnosis, Description of Injury, Special Requests

Assessments Type
Physical Assessments	Medical File Review In-Person Examination
Anesthesiology Gastroenterology Neuro-Opthamology Orthopedic Surgery Rheumatology Audiology General Practitioner Neurology Otolaryngology (ENT) Social Worker Cardiology General Surgery Neurosurgery Pediatrics Speech Language Pathology Chiropractic Hematology Occupational Medicine Physiatry Thoracic Surgery Dentistry Immunology Oncology Physiotherapy Urology Dermatology Infectious Disease Ophthalmology Plastic Surgery Vascular Surgery Endocrinology Internal Medicine Oral Surgery Respirology
Other:
Psychological / Psychiatric Assessments
Neuropsychology Psychiatry Psychology
Funcational & Vocational Assessments
Job Site Analysis (JSA/PDA) Functional Abilities Evaluation (FAE/FCE) Ergonomic Assessment
Vocational Vocation with TSA & LMS Psychovocational
Diagnostics Imaging
Bone Scan CT Scan MRI X-ray

Additional Services To Be Arranged By A.R.S.
The following services will be arranged by A.R.S. at no additional administrative cost.
Interpreter Required?	Yes No		Language
Transportation Required?	Yes No	Ground Air	Pickup Address:
Accommodation Required?	Yes No		Instructions:
Would you like A.R.S. to initiate direct contact with the employee strictly to communicate the appointment details?			Phone Letter Phone or Letter No Direct Contact

Comments / Special Instructions

Optional Referral Questions

Please indicate which questions you would like the assessor(s) to answer in their medical report after the assessment has taken place

Within the scope of your medical/professional discipline, what are the examinee’s primary & secondary diagnoses? Within the scope of your medical/professional discipline, what is examinee’s prognosis? Within the scope of your medical/professional discipline, what are the present barriers to the examinee’s recovery, if any? Within the scope of your medical/professional discipline, what are the examinee’s present physical restrictions, if any? And how are those restrictions being addressed by way of treatment? Within the scope of your medical/professional discipline, is further medical investigation required? If so, what investigations and why? Within the scope of your medical/professional discipline, does the examinee require treatment of any kind? If so, what is the frequency and duration recommended? Within the scope of your medical/professional discipline, can the examinee’s reported symptoms be supported by the existence of objective clinical pathology? Within the scope of your medical/professional discipline, are there any further considerations or recommendations you might suggest in order to enhance this individual’s return to maximum functioning? Within the scope of your medical/professional discipline, what is the present psychological status? Please include the resulting DSM IV code, if applicable. Is this condition permanent or temporary? Within the scope of your medical/professional discipline, do your objective findings indicate any cognitive deficits? If yes, please indicate the estimated duration of impairment. Within the scope of your medical/professional discipline, do you suspect functional overlay requiring psychological attention or assessment? Within the scope of your medical/professional discipline, do you consider the rate of progress to be satisfactory in this case? Within the scope of your medical/professional discipline, is anything impeding further, or a more timely, recovery? Within the scope of your medical/professional discipline, is the examinee able to resume full-time work at this time? a) If yes, please provide a specific return to work date. If there is a delay to the examinee’s return to work, please provide your rationale. b) If the examinee is able to resume full-time work, can the examinee return to regular full time duties? If not, please provide your recommendations and rationale. c) If the examinee is medically unable to resume full-time work, when will they be able to do so? Please provide your recommendations and rationale. Within the scope of your medical/professional discipline, is the examinee able to resume part-time work at this time? a) If yes, please provide a specific return to work date. If there is a delay to the examinee’s return to work, please provide your rationale. b) If the examinee is able to resume part-time work, can they return to their regular duties? If not, please provide your recommendations and rationale. c) If the examinee is medically unable to resume part-time work, when will they be able to do so? Please provide your recommendations and rationale. Within the scope of your medical/professional discipline, is the examinee capable of modified return to work at this time? If so, please detail the modified return to work plan, including but not limited to the following: i) clearly defined timelines (days, weeks, hours/day; ii) full or part time; iii) clearly outline and quantify restrictions/limitations; and iv) same position or new position? Within the scope of your medical/professional discipline, is the examinee capable of graduated return to work at this time? If so, please detail the graduated return to work plan, including but not limited to the following: i) clearly defined timelines (days, weeks, hours/day; ii) modified or regular duties; iii) clearly outline and quantify restrictions/limitations; and iv) same position or new position? Please indicate if there had been any non-medical barriers which have or are preventing a return to gainful employment.

Additional Questions: