Form 113b - Summary Of Medical Record - Occupational Exposure
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2Form 113b Revised 3/2010
SUMMARY OF MEDICAL RECORD – OCCUPATIONAL EXPOSURE
(Please attach additional pages if necessary)
Petitioner’s Name: _____________________________ Date of Industrial Accident: _____________
Employer’s Name: _____________________________
1. Diagnosis
What is your impression/diagnosis of the petitioner’s medical problem(s)?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
2. Causation/Aggravation
Did the petitioner’s occupational exposure during employment with the employer medically cause or
aggravate the medical problem(s) described above? ___Yes ____No
If the occupational exposure during employment with the employer caused an aggravation of
petitioner’s medical problem(s), is it a _____ temporary or ______ permanent aggravation?
Is the sole cause of the petitioner’s medical problem(s) described above due to the occupational
exposure during employment with the employer? ___Yes ____No
If no, please state separately and with specificity all other causes that have aggravated, prolonged,
accelerated or in any way contributed to the petitioner’s medical problem(s).
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
To what extent, by percentage, has another cause contributed to petitioner’s medical problem(s)?
__________________________________________________________________________________
3. Work Release/Medical Stability
Have you released the petitioner from work as the result of the medical problem(s) caused or
aggravated by the occupational exposure during employment with the employer? ___Yes ____No
If yes, on what date? _____________________________________
Have you released the petitioner to work with medically prescribed functional limitations (“light
duty”) as the result of the medical problem(s) caused or aggravated by occupational exposure during
employment with the employer? ___Yes ____No
If yes, on what date and describe in detail the functional limitations? ___________________________
Have you released the petitioner to return to work with no restrictions? ___Yes ____No
If yes, on what date? _________________________________________________________________
Is the petitioner medically stable (stabilization means that the period of healing has ended and the
condition of the petitioner will not materially improve) with respect to the medical problem(s) caused
or aggravated by the occupational exposure during employment with the employer? ___Yes ____No
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Parent category: Medical