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Medical
Progress Report
Worker Information
Last Name First Name
Mailing Address (include postal code) Community Telephone (include area code)
Employer Worker’s Occupation
Date of Injury MM DD YY Date of Birth MM DD YY
Gender
M
F
Health Care Provider Information
Name of Health Care Provider (please print) Address (include postal code)
Telephone (include area code)
Date of Exam MM DD YY Time
Subjective/Objective
Any change in diagnosis?
Yes (please explain)
No
Describe subjective complaints.
Describe objective findings and lab or x-ray results.
Treatment plan and medication:
Investigation
Refer to Specialist?
Yes
No If yes, will you arrange this?
Yes
No
Type of Specialist
Date of follow-up visit MM DD YY If worker's abilities have significantly changed,
complete Functional Abilities on the reverse
side, and provide a copy to the worker.
Refer to WSCC Medical Advisor?
Yes
No
For
Factors complicating recovery
Yes (please explain)
No
Complete this form and return it, with your invoice,
to the address on the reverse.
CS004 0713
The WSCC may use this information for the administration of the Workers’ Compensation Acts, the Safety Acts, and/or the Mine Health and
Safety Acts, and their associated Regulations.
I hereby certify the above is a correct statement of services personally rendered by myself.
Health Care Provider’s Signature Date
Please print form to sign.
MM / DD / YY