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Referral Date:

(mm/dd/yyyy)

Evaluee
*Name:
*Date of Birth:		Gender:	Male Female
Address 1:
Address 2:
Telephone:
*Date of Loss:		*File Number:
Pre-Injury Occupation:
Impairment:

Employer Information
Company Name:
Contact Name:
Address 1:
Address 2:
Telephone:		Fax:
Email:

Examinee Treating Physician
Name:
Address 1:
Address 2:
Telephone:		Fax:

Type of Assessment
	Functional Neurological Psychiatric IME - Ortho Neuropsychological Psychological IME - Physiatry OT Assessment Vocational Job Demands Analysis
Other:

Additional Services To Be Arranged AssessMed
Interpreter Required?	Yes No	Language:
Transportation Required?	Yes No
Accommodation Required?	Yes No

Final Report / Special Instructions
	Full MEDICAL Reports to be released
	NON MEDICAL SUMMARY ONLY to be released to the referral source (full Medical report will be forwarded to the examinee's treating physician)

Optional Referral Questions

FULL MEDICAL REPORT QUESTIONS Please select any questions you would like the evaluator(s) to answer in the final report:

Within the scope of your medical discipline, what is examinee’s primary & secondary diagnosis Within the scope of your medical discipline, what is examinee’s prognosis? Within the scope of your medical discipline, what are the present medicals barriers to the examinees recovery, if any? Within the scope of your medical discipline, is the examinee able to resume full-time work at this time? If not, when will the examinee be capable of doing so? Within the scope of your medical discipline, what are the examinees present physical restrictions, if any? And how are those restrictions being addressed by way of treatment? Within the scope of your medical discipline, is the examinee capable of graduated return to work at this time? If not, when will the examinee be able to do so? If applicable, please detail the graduated return to work plan. Within the scope of your medical discipline, does the examinee require medication? Within the scope of your medical discipline, please comment on the reasonableness of the examinees current treatment as to benefit & therapeutic value. Within the scope of your medical discipline, does the premorbid medical history suggest that the examinee would have exhibited physical restrictions that would have limited his/her functional abilities prior to your examination? Within the scope of your medical discipline, do you suspect any abnormal underlying pathology requiring further medical investigation? If yes, please explain. Within the scope of your medical discipline, has maximum medical recovery (MMR) been achieved? If not please indicate an anticipated time frame. If MMR has been reached, please provide an explanation for concluding that the condition is stable and stationary and unlikely to change. Within the scope of your medical discipline, do you recommend any further treatment / assistive devices to reduce and/or eliminate these restrictions? If so, please indicate type & frequency. Within the scope of your medical 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 discipline, what is the present psychological status with the resulting DSM IV code? Is this permanent or temporary? Within the scope of your medical discipline, do your objective findings indicate any cognitive deficits as a result of the accident? If yes, please indicate the estimated duration of impairment. Within the scope of your medical discipline, are the examinees cognitive abilities intact and is there normal thought process present? Please comment. Within the scope of your medical discipline, do you consider the rate of progress to be satisfactory in this case? Within the scope of your medical discipline, is further medical investigation required? If so, what investigations and why? Within the scope of your medical discipline, has the examinee been following the recommended treatment protocol prior to your examination? Within the scope of your medical discipline, is anything impeding further or a more timely recovery? Please indicate if there are any non-medical barriers which have or are preventing a return to gainful employment.

NON MEDICAL REPORT QUESTIONS Please select any questions you would like the evaluator(s) to answer in the non-medical summary:

Within the scope of your medical discipline, is the examinee able to resume full-time work at this time? If not, when will the examinee be capable of doing so? If applicable, please detail the graduated return to work plan. Please indicate if there are any non-medical barriers which have or are preventing a return to gainful employment. Your opinion regarding the examinee’s ability to perform any occupation for which he/she has the minimum qualifications. If an alternative occupational role has been offered please specify

Additional Questions:

In addition to any medical information you have, please also forward to our office a full job descriptions and/or Physical Demands Analysis (PDA) if you have one completed. If you do not have one completed, please advise and AssessMed can provide one for you at an additional cost.