MUSCULOSKELETAL DEFECTS OR FRACTURES


Patient Name: _______________________________________

Social Security #: _____________________________________

TO THE DOCTOR: Please complete the following report attaching copies of lab results for each condition. Please use the back of the form if additional space is needed.

1. Does this patient suffer from any impairment or disease of the musculoskeletal system?    ____YES  ____NO.  

If yes,

A. What is the current diagnosis? ___________________________________________
____________________________________________________________________
B. On what date was the diagnosis first made? _________________________________
C. What is the date of onset, if different? ______________________________________
D. How long have you been treating the condition? ______________________________
E. What is the date of the most recent examination? _____________________________
F. What was the patient's height_____ weight ____ at that time?
2. Location of fracture(s): _________________________________
3. Have any of the following diagnostic techniques been performed?
      Yes No
      Xray ____ ____
      CT Scan ____ ____
      EMG Studies ____ ____
4. Functional loss - describe the following:

A. Limitation of motion in involved areas:_____________________________________
____________________________________________________________________
____________________________________________________________________
B. Is there any atrophy? Yes_____ No ______
C. Is there any weakness or swelling? Yes_____ No _____
D. Is there any deformity(s)? Yes_____ No _____
6. Ambulation: normal_______ bedfast_______ cane_______ crutches_______ wheelchair_______ walker_______
7. Is the degree of pain described by patient reasonably related to the fracture or realted underlying impairments? Yes_____ No _____
8. Since the date of onset, has the patient had full recovery? Yes_____ No _____
9. If not, is the condition improving_______ stable_______ deteriorating_______
10. Since the date of onset, has the patient had full recovery? Yes_____ No _____
     If yes, what procedures?___________________________________________________
     What date?______________What hospital?____________________________________
11. Does the patient suffer from acute pain? Yes_____ No_____
     If yes, please describe?___________________________________________________

     Please complete the the following Physical Capacities form. (Musculoskelatal Exam Sheet)

MUSCULOSKELETAL DEFECTS OR FRACTURES

OVERALL RANDE OF MOTION (ROM)

The normal range is marked below in degrees, record patient's actual range next to the normal range. Also record the presence of pain, and the condition of the joint, using the legend provided for joint condition

Joint Condition
PVMS Paravertabral Muscle Spasm
PMW Periarticular Muscle Wasting
T Tenderness
W Warmth
R Redness
S Swelling


Presence Joint
  ROM   Presence
of Pain		 Joint
Condition
SPINE Lumbosacral flexion 90 _____ __________ __________
  Lumbosacral extension 20 _____ __________ __________
  Cervical flexion 30 _____ __________ __________
  Cervical extension 300 _____ __________ __________
HIP Right flexion 100 _____ __________ __________
  Left flexion 100 _____ __________ __________
  Right extension 30 _____ __________ __________
  Left extension 30 _____ __________ __________
  Right rotation 40/40 _____ __________ __________
  Left rotation 40/40 _____ __________ __________
KNEE Right flexion 150 _____ __________ __________
  Left flexion 150 _____ __________ __________
  Right extension 180 _____ __________ __________
  Left extension 180 _____ __________ __________
SHOULDER Right abduction 150 _____ __________ __________
  Left abduction 150 _____ __________ __________
ELBOW Right flexion 150 _____ __________ __________
  Left flexion 150 _____ __________ __________
  Right extension 180 _____ __________ __________
  Left extension 180 _____ __________ __________
WRIST Right flexion 70 _____ __________ __________
  Left flexion 70 _____ __________ __________
  Right extension 70 _____ __________ __________
  Left dorsal 70 _____ __________ __________

  Dexterity Fist Grip
  Abnormal Normal Abnormal Normal
HAND Right Gross _________ _________ _________ _________
    Fine _________ _________ _________ _________
  Left Gross _________ _________ _________ _________
    Fine _________ _________ _________ _________

12. Have any surgical procedures been performed? Yes_____ No _____ (please describe)
  _____________________________________________________________________
  _____________________________________________________________________
  _____________________________________________________________________
13. Straight Leg Testing Results (Negative or Positive and if positive what degree)
  _____________________________________________________________________
  _____________________________________________________________________
  _____________________________________________________________________
14. Ambulation: Normal _____ Cane _____ Crutch _____ Walker _____
  If assistance was prescribed, as of what date?_________________
15. Has patient complained of any joint pain? Yes _____ No _____
  A. Please describe joints involved:
  _____________________________________________________________________
  _____________________________________________________________________
  B. Is there any inflammation, swelling, or redness of each involved joint?
  _____________________________________________________________________
  _____________________________________________________________________
  C. Has the condition lasted for more than 3 months despite therapy for each joint? (please describe)
  _____________________________________________________________________
  _____________________________________________________________________
  D. Is condition expected to last for more than 12 months? (please specify which joints)
  _____________________________________________________________________
  _____________________________________________________________________
  E. Does patient have signs or symptoms of pain not corroborated by clinical findings? (please describe)
  _____________________________________________________________________
  _____________________________________________________________________
  F. Describe treatment prescribed:
  _____________________________________________________________________
  _____________________________________________________________________
  G. Patient's response to treatment:
  _____________________________________________________________________
  _____________________________________________________________________
16. Please describe x-ray findings for involved joints and/or attach copy with results.
  _____________________________________________________________________
  _____________________________________________________________________
  _____________________________________________________________________
17. Medications prescribed? Yes______ No_____
  If yes, what are the medications and dosage?
  _____________________________________________________________________
  _____________________________________________________________________
  _____________________________________________________________________
18. Is the patient suffering from side effects from the medications? Yes_____ No_____ If so, please specify.
  _____________________________________________________________________
  _____________________________________________________________________
19. Any other comments or observations:
  _____________________________________________________________________
  _____________________________________________________________________
  _____________________________________________________________________


Date Report Completed: ______________________________
Signature of Physician: ______________________________
Physician Name: ______________________________
Address: ______________________________
Telephone: ______________________________
Specialty: ______________________________

Law Office Of:
Jerrold S. Zivic
850 W. Jackson Blvd.
Suite 405
Chicago, IL 60607
800-400-4357