1048 Aps-A - Attending Physician'S Statement For Disability Benefits
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1
2Attending Physician’s Statement for
Disability Benefits
Instructions:
1. Please PRINT.
2. Part 1 to be completed by patient.
3. Part 2 to be completed be physician.
To allow us to make an assessment of your patient’s claim it is IMPERATIVE
4. Any charge for completing this form is the
that you answer ALL of the questions in FULL.
patient’s responsibility.
1
Patient Authorization
Name
Date of birth (d,m,y)
Policy and certificate no.
I hereby authorize and request all medical practitioners who may have attended me and all hospitals, government authorities, pension boards, employers or other
persons to furnish The Canada Life Assurance Company or its accredited representatives all information including consultation Reports, in their possession or within
their knowledge and to honour a photostatic copy of this authorization. I hereby appoint Canada Life as my agent or representative for the purpose of obtaining the
above mentioned information.
Patient’s signature
Date (d,m,y)
2
Attending Physician’s Questionnaire
1. HISTORY
Onset of symptoms (d,m,y)
Date of latest attendance (d,m,y)
Date of first visit (d,m,y)
Frequency of visits
Other treating physicians
Weekly
Monthly
Other
2. RHEUMATOID ARTHRITIS
List joints involved
Is objective evidence of synovitis and joint deformity present?
Yes
No
Is contracture, ankylosis or impaired range of motion present?
Yes
No
If “Yes”, please describe:
Check laboratory findings and attach copies of lab results
Positive synovial fluid findings
A.N.A. (Normal _____)
Histologic change from biopsy
Rheumatoid factor titer (Normal _____)
Other
Sedimentation rate (Normal _____)
Are X-ray findings characteristic of, or compatible with Rheumatoid Arthritis?
Results of surgical treatment
Yes
No
3. OSTEOARTHRITIS
List joints involved
Is joint deformity and/or limitation of motion present? If “Yes”, please describe
Yes
No
Symptoms (please describe severity, frequency and duration)
Are X-ray findings characteristic of degenerative joint disease?
Yes
No
Results of medical or surgical treatment
4. OTHER RHEUMATIC DISEASES
Reiter’s Syndrome
Ankylosing spondylitis
Connective tissue disorders
Other
List positive or negative laboratory results
Symptoms (please specify severity, frequency and duration)
Do X-ray findings confirm diagnosis? If “Yes”, please describe
Yes
No
PLEASE INCLUDE COPIES OF RELEVANT TEST RESULTS
1048 APS-A 11/05
continued on back
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