Wage Loss - Annual Medical Report

This information is being collected for the purpose of administering and enforcing the Workers’ Safety and Compensation Act in compliance with the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the board’s privacy officer at 401 Strickland St., Whitehorse, YT, Y1A 5N8 or call 867-667-5645 or 1-800-661-0443.

In partnership with the worker, the board annually reviews wage loss claims. Your assessment of functional abilities regarding the worker’s workplace injury is important to assist the board with this review.

Please fax your separate invoice to the board at 1-867-667-8740. If you are a YMA member, please use code M0901 Progress Report for invoicing. All other health care providers can invoice for a wage loss progress report.

Service Provider Information

Legal Name

Street Number

Unit Number

Street Name

City

Province/Territory

Country

Postal Code

Primary phone number

Fax

Type of Health Care Provider

Family Physician Psychiatrist/Psychologist/Counsellor Physiotherapist Chiropractor Other ____________________________________

Worker Information

Claim Number

First Name

Middle Name

Last Name

As shown on valid government-issued ID

Street Number

Apartment Number/Unit Number

Street Name

City

Province/Territory

Country

Postal Code

Primary Phone Number

Injury and Functional Information

What is the workplace injury?

Exam date

How long have you known/treated the worker?

1 month 6 months 1+ year

In the last year, the worker’s work-related injury has:

improved stabilized declined

Please explain the changes

In the last year, has there been any treatment given to the worker for the work-related injury?

Yes No

Has the worker’s medication for the work-related injury changed in the last year?

Yes No N/A

Physical Workplace Injury

If this is a physical workplace injury, please check off the functional abilities the worker is able to do

Participate in vigorous activities (e.g. soccer, running, moving heavy furniture) Participate in moderate activities (e.g. golf, bowling, vacuuming, carrying groceries) Bend, kneel or stoop Independent self-care

Lift/Carry

Light weight (10 to 20 lbs.) Medium weight (20-50 lbs.) Heavy weight (50 + lbs.)

Climb stairs

Up to one flight of stairs More than one flight of stairs

Walk

less than 1 km between 1 km - 5 km + 5 km Other: _________________________________________

For all unchecked boxes, please provide further details.

Psychological Workplace Injury

If this is a psychological injury, please check off the functional abilities the worker is able to do:

Social activities/errands (e.g. shopping, parties and community events) Interactions with family and friends Concentration (reading, driving, multi-tasking) Memory (remembering errands, groceries or details from a book) Complex thinking such as managing finances or money Independent self-care Other: __________________________________________

For all unchecked boxes, please provide further details.

Please assess the worker’s overall health.

Excellent Good Fair Poor

Please explain

Please provide any further relevant information

Signature, consent and declaration

I acknowledge that electronic communication has inherent security risks, as do all forms of communication. Notwithstanding the inherent risks of electronic communication, I consent to the use of electronic methods to transmit and receive information, including confidential and personal information between the board and myself. This consent will remain in effect until written notice to revoke this authorization has been received by the board.

By checking this box I declare that the information provided is true and correct.

My name is

Date

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