Safety & Loss Prevention

Camp & Clinic Physician's Report

PHYSICIAN'S REPORT
(To Be Completed By the Attending Physician)
1. PATIENT'S NAME

2. NATURE OF INJURY
(DESCRIBE
COMPLICATIONS,
IF ANY)
3. DESCRIBE ANY
PRE-EXISTING
CONDITION OR
OTHER DISEASE OR
INFIRMITY WHICH
MAY OR MAY NOT
AFFECT PRESENT
CONDITION
4. GIVE DATES
OF
TREATMENTS
OFFICE

HOME

HOSPITAL
     

5. IS YOUR PATIENT
DISABLED?
 _____YES
_____NO


 IF YES
_____TOTAL
_____PARTIAL      
DATE: 		ABLE TO WORK      
ON:
DATE:

 RESUMED WORK      
ON:
DATE:
6. FACTORS PRESENT
PROLONGING
DISABILITY
7. IS PATIENT STILL
UNDER YOUR CARE
FOR THIS
CONDITION?		 _____YES
_____NO		 CONTEMPLATE
DISCHARGE DATE:


 IF DISCHARGED, GIVE DATE:
8. AMOUNT OF YOUR
BILL FOR
SERVICES TO DATE


PHYSICIAN'S SIGNATURE______________________________________ Date___________

STREET ADDRESS____________________________________________________________

CITY OR TOWN_______________________________________STATE______ZIP________

TELEPHONE NUMBER (______) ______-________