Your name
Address
Phone #
FORENSIC MEDICAL[JH1]REPORT
Personal Injury
Subject’s Name
Case #:
DOB:
Date
REASON FOR REFERRAL:
The purpose of this evaluation is to determine whether _____has experienced physical or emotionalharm[JH2]resulting from ____.
I performed this evaluation at the request of _____.
OPINION:
It is my opinion, with a reasonable degree of medical certainty, that _____ did[JH3]sustain physical or emotional injuries as a result of _____.
SOURCES OF INFORMATION:
1.Examination of _____ for _____hours on _____
2[JH4].
CONFIDENTIALITY:
At the start of the interview, I explained to _____ the purpose of the evaluation, my role, and the limits of confidentiality.
CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS/INJURY:
______is a _____ year-old….
Description of the injury [JH5]in context
Subsequent treatment and work-up
Concurrent illnesses related to or impacted by the injury
Pre-existing functioning on the job and in personal life
Subsequent functioning and changes in lifestyle
Details of current job/family dynamics, expectations, performance, and accommodations
Attitudes towards job, employment, co-workers, family
Attitudes towards injury, treatment, and current providers
Identified resources/supports and potential stresses
Future plans
RELEVANT PAST HISTORY:
Medical Illnesses:
Injuries:
Operations/Medical Procedures:
Obstetric [JH6]History:
Hospitalizations:
Allergies:
Past Medications[JH7]:
Substance Use:
Psychiatric History:
Family History:
Social History:
Past Employment:
Review of Symptoms:
PHYSICAL EXAMINATION:
Vital Signs:
General:
Head, ears, eyes, nose, throat:
Chest:
Abdomen:
Genital/rectal:
Musculoskeletal:
Inspection/palpation
Range of motion
Strength (or see neurological)
Neurological:
Mental status
Cranial nerves
Motor strength
Reflexes
Sensation
Coordination/gait
DIAGNOSTIC STUDIES:
CURRENT MEDICATIONS:
DIAGNOSES:
FORMULATION:
Clinical [JH8]formulation of illness/injury
Causal connection [JH9]
Did the injury cause a new illness or exacerbate [JH10]an old one?
Prognosis[JH11]:
Treatment needs and duration?
Impact of disability on employment/earnings, family/relationships, lifestyle?
Is disability partial or total? Is the injury permanent, or is improvement expected?
Respectfully submitted,
Your name
Title/certifications
1
[JH1]Or insert your specialty.
[JH2]You may wish to modify this sentence so that it essentially restates the plaintiff’s claim.
[JH3]Or did not.
[JH4]List all available health and employment records as well as interviews with family members or other providers.
[JH5]If the facts of the injury are in doubt, you may need to provide different opinions in your formulation that address the different factual scenarios. At this point, you can present the data from different sources, even if they are conflicting.
[JH6]Women only.
[JH7]Include over-the-counter.
[JH8]Explain the diagnoses you have made, including pre-existing illnesses. Summarize the course of illness without getting into the causal connection.
[JH9]Discuss etiology, considering potential alternative causes, pre-existing conditions, other stresses, role of personality, and secondary gain. Also, it may be relevant if the plaintiff’s own behavior contributed to the injury.
[JH10]Would the illness have occurred at all in the absence of the injury? What would have been the course of pre-existing illness in the absence of the injury? Was the plaintiff uniquely vulnerable to the injury (the last question may be legally relevant to mental injury but irrelevant to physical injury)?
[JH11]The following factors may help the fact finder determine the appropriate level of compensation.