Mail to:
200 Front Street W.
Toronto ON
M5V 3J1
Fax to:
416-344-4684 or
1-888-313-7373
Musculoskeletal
Program of Care (MSKPOC)
Initial Assessment Report
Claim Number
For an injury to: (select one)
Upper body (excluding the shoulder)
Lower body (excluding the lower back)
Please PRINT in black ink.
A. Worker & Employer Information Section
Init.
Last Name
First Name
Address (no. street, apt.)
City/Town Postal Code Telephone
Prov.
( )
Date of Birth (dd/mmm/yyyy)
Date of Injury (dd/mmm/yyyy)
Sex
F
M
Telephone No.
Supervisor/Contact Name
Employer Name
( )
Worker's Current Job Title/Occupation
Length of time
in current job:
months years
Employment status at time of assessment:
Full time OR Part time Not working
Please ask the worker before assessment:
If not working, how long do you think you
will be off work?
Regular duties OR Modified duties
Regular hours OR Modified hours
days
B. Health Professional Information
Chiropractor Physiotherapist Other, please specify:
Facility Name
Health Professional Name (please print)
City/Town Postal Code
Address (no. street, apt.) Prov.
Telephone Date of initial assessment (dd/mmm/yyyy)
( )
C. Clinical Information
2. Date of referral (dd/mmm/yyyy)
1. Name of the referring health professional (if applicable)
3. Worker’s history of injury:
4. Area(s) of injury:
5. Pertinent Clinical Signs:
6. Working Diagnosis:
7. Additional information:
2345A (01/14) Page 1 of 2
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