tion of plant where accident occurred-Street and No.--- City or village-----. _Date______ The Injured Person. Hour__ ..M Name in full‒‒‒‒‒‒‒‒‒‒‒‒City or town‒‒‒‒‒‒‒‒‒‒‒‒Address-Street and No.------ --Occupation‒‒‒‒‒‒ Married or single---- _Sex Does patient pay hospital dues?‒‒‒‒‒‒‒‒‒‒‒‒Is patient left or righthanded?____________Has the patient been maimed or crippled by any previous injury?‒‒‒‒‒‒ If so, what?_ The Injury. Give description, stating the parts injured and supposed manner of infliction, marking upon the chart upon the back of this report, the site of injury--- Where treated_‒‒‒‒‒‒‒‒‒‒‒Hour of treatment_-_rendered first treatment and what was done__. -State who State name and address of consultant or assistant... Give description of treatment... What was done with patient?------------Are the symptoms from \ which he is suffering due to the aforesaid accident, or are they traceable to any previous accident, or other cause, and if so, what? Medical Attendance. Name of attending physician Office address Street and No City or town__. Disability. Is the injury of so serious a nature as to wholly disable and prevent him from attending to any and all kinds of duties pertaining to his present occupation, or any other occupation?_. If not wholly disabled, to what extent disabled?_. Is he confined to the house?‒‒‒‒‒‒‒‒‒‒‒‒If not confined to the house, why do you consider that he is unable to attend to any part of his duties? State opinion as to length of time patient will be disabled__. State any additional information which you deem of interest as to extent of disability, impairment of earning capacity, etc. (This report must contain account of all injuries no matter how trivial.) I hereby certify that I am the attending physician of the injured person above mentioned; that I have set forth in the foregoing report all the facts in the case and that the statements contained therein are true and correct. (Signed). Attending Physician. Date signed---. (This form should be made out and forwarded to the office of the Commission in Olympia as soon as surgeon has made such careful examination as will enable him to make an intelligent report of the case. No fee is paid for making out this blank, but the Commission respectfully urges the co-operation of attending physicians in getting the real facts of each case before it. N. B. Your patient cannot receive any Compensation from the State until this form is received and passed upon by the Chief Medical Advisor of the Commission.) § 147. Form of surgical discharge report (n): I hereby notify you that‒‒‒‒‒‒‒‒‒‒‒‒who came under my care at __on_the____________day of------------, 191, having been injured at the plant or premises of‒‒‒‒‒‒‒‒‒‒‒_at_‒‒‒‒‒ on the‒‒‒‒‒‒‒‒‒‒day of---------- 191, was disccharged from treatment, the‒‒‒‒‒‒‒‒‒‒‒‒day of‒‒‒‒‒‒‒‒‒‒‒‒191. ---) -- 1. Developments which have retarded recovery. 2. What operation, if any, performed since original report?__ 3. His condition is___ 4. State whether in your opinion any permanent disability will follow‒‒‒‒‒‒‒‒----If so, what?-- 5. The time of treatment was. pital_--_--_--___days. ---days. 6. Was in hos ------day of 7. Will be able to resume work on or about the____ 191___ 8. If patient has already resumed work, for how many days was he unable to work?------ 9. Inclination of patient to follow surgeon's directions.. 10. *For statistical purposes only, please give the following data: Cost of medical and surgical treatment.‒‒‒‒‒‒‒‒ $ Cost of medicine, medical and surgical supplies. $. Cost of crutches and apparatus___ Hospital charges Ambulance charges Cost of nurse___. *Note: The above information will be held strictly confidential, and only used in the form of general tables, no individual figures being shown. at Surgeon This report must be made out and forwarded to Olympia as soon as patient is discharged from professional care. § 148. Form of report of witnesses (o): (Fill in all blanks with ink or indelible pencil.) Employer, Place, and Time, Employer's name Location of plant where accident occurred-Street and No-City or village.... ... Irate on which accident occurred.. Hour of day.... |