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Physiotherapy Reports
Physiotherapy progress report New
Physiotherapy progress and discharge report
Download Printable Form
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 867-667-5642 or 1-800-661-0443.
Worker Information
First Name
As shown on valid government-issued ID
Last Name
As shown on valid government-issued ID
Also known as
Street Number
Apartment Number/Unit Number
Street Name
City
Province/Territory
Please select
Yukon
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Northwest Territories
Nunavut
Saskatchewan
Other
Postal Code
Country
Primary Phone Number
Work Phone Number
Date of Birth
Claim Number
Part of body affected (check all that apply)
Left Fingers
Left Hand
Left Wrist
Left Forearm
Left Elbow
Left Shoulder
Left Neck
Left Upper Back
Left Lower Back
Left Hip
Left Knee
Left Foot
Left Other
Right Fingers
Right Hand
Right Wrist
Right Forearm
Right Elbow
Right Shoulder
Right Neck
Right Upper Back
Right Lower Back
Right Hip
Right Knee
Right Foot
Right Other
Date of injury
Employer
Heath care provider information
Clinic Name
Therapist Name
Street Number
Apartment Number/Unit Number
Street Name
City
Province/Territory
Please select
Yukon
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Northwest Territories
Nunavut
Saskatchewan
Other
Country
Postal Code
Email
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
Primary Phone Number
Fax Number
Reassessment Date
Treatment Summary
Treatment dates since last report
Has the worker missed any appointments
Yes
No
Overall functional progress
Improving
No change
Declining
Objective Findings
Observation findings
ROM and Biomechanical Analysis
Strength
Neurological
Special test and results
Test name
Result
Checkbox
none
Worker's current occupation
List the worker's five most critical job demands
Critical job demand
Current ability
Job match
Is the Job Demands Analysis for this occupation needed?
Yes
No
Treatment plan
Treatment goals
Recommended treatment (Methodology)
Frequency and expected duration of treatment
# of visits/week
Duration
Recommended or prescribed equipment or supplies.
Return to work
Based on current functional abilities, can regular duties be performed?
Yes
No
Are there barriers to recovery or return to work?
Yes
No
Severe injuries with likely long term or permanent work restrictions
Has a Functional Abilities Form (FAF) been given to the worker?
Yes
No
Additional comments
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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.
Checkbox
By checking this box I declare that the information provided is true and correct. I consent to the release from any third party to Workers' Safety and Compensation Board (Board) of any medical, employment or other information relevant to my claim. I consent to the Board disclosing to health care providers, hospitals, physicians, my employers, other workers' compensation boards, and any other relevant third parties, all relevant information necessary to administer my claim in accordance with the law.
My name is
My email is
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