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PT Initial Assessment Form B Feb09

This document contains a physical therapy initial assessment form for a worker who was injured on the job. It includes sections for worker information, employer information, injury details, physical abilities, treatment plan, and health care provider details. The form also provides definitions for terms like transitional duties, work classifications from sedentary to very heavy, and guidelines for frequent and occasional weight tolerances.

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Leonardo Lopez
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189 views2 pages

PT Initial Assessment Form B Feb09

This document contains a physical therapy initial assessment form for a worker who was injured on the job. It includes sections for worker information, employer information, injury details, physical abilities, treatment plan, and health care provider details. The form also provides definitions for terms like transitional duties, work classifications from sedentary to very heavy, and guidelines for frequent and occasional weight tolerances.

Uploaded by

Leonardo Lopez
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Halifax Office Sydney Office PT Initial Assessment

1-800-870-3331 toll free 1-800-880-0003 toll free


902-491-8999 local 902-563-2444 local Form B
902-491-8001 fax 902-563-0512 fax
WCB Claim Number:

Health Card Number:


Date of Assessment:

Worker Information
Worker’s Last Name First Name Initial Date of Birth (dd/mm/yyyy)

Date of Injury (dd/mm/yyyy):


Is the worker working? Yes No If yes, describe: transitional duties preinjury work

Employer Information (to be completed by health care provider)


Employer Name Employer Contact Name Employer contacted?
Yes No Response
Worker’s Job Title/Occupation
Job task information available? Yes No Transitional duties available? Yes No

Injury Assessment Information (to be completed by health care provider; attach additional page if necessary)

MDA Diagnosis (specify body part):


Date of Referral (dd/mm/yyyy): DDG Date (dd/mm/yyyy):
Significant Objective: Significant Subjective:

Physical Abilities Report? Yes No If no, why?


Functional Abilities:

Are there flags that influence duration? Orebro questionnaire score: Expected RTW Date (dd/mm/yyyy):

Yes No Transitional Pre-Injury

Job Match Summary


(to be completed by health care provider; see over for definitions – complete if Physical Abilities Report not attached)
Describe preinjury job requirements: Sedentary Light Medium Heavy Very Heavy
Describe present work capability: Sedentary Light Medium Heavy Very Heavy N/a
Describe transitional duties: Sedentary Light Medium Heavy Very Heavy

Recommended Treatment Plan (to be completed by health care provider)


Goals Methodology Recommended Time Frame (specific dates)
From To
From To
From To

Health Care Provider Information (to be completed by health care provider; please print)

Name of Clinic: ID#:

Name of Practitioner: Phone: Fax:

WCB Response (to be completed by WCB Case Worker)


Yes – for treatment from to Screen 119 updated Yes Initials:
No – Reason:
WCB Case Worker (print): Phone: Date (dd/mm/yyyy):
12/2008
Work Capabilities ⎯ Definitions*

Transitional Duties Suitable Work


• A temporary change in or adaptation of the pre- • A different job with duties within the worker’s
injury work or schedule, based on the worker’s capabilities.
capabilities.

Work Classifications
The following are five work classifications used to describe the amount of physical effort required to perform a task or
job. These classifications are referred to on various WCB forms, and are used by health care providers and the WCB
to assist with planning treatments and return-to-work initiatives.
SEDENTARY Work
• Exerting up to 4.4 kg (10 lbs) of force occasionally and/or a negligible amount of force frequently.
Example: An occupation where the worker sits most of the time, and only walks or stands for brief periods.
LIGHT Work
• Exerting up to 8.9 kg (20 lbs) of force occasionally and/or up to 4.4 kg (10 lbs) frequently and/or negligible amounts
constantly.
Example: Walking or standing to a significant degree, or sitting constantly but with arm and/or leg controls with
exertion of force greater than sedentary.
MEDIUM Work
• Exerting up to 22.2 kg (50 lbs) of force occasionally and/or up to 8.9 kg (20 lbs) of force frequently and/or up to 4.4
kg (10 lbs) constantly.
HEAVY Work
• Exerting up to 44.4 kg (100 lbs) of force occasionally and/or up to 22.2 kg (50 lbs) of force frequently and/or up to
8.9 kg (20 lbs) of force constantly.
VERY HEAVY Work
• Exerting in excess of 44.4 kg (100 lbs) of force occasionally and/or in excess of 22.2 kg (50 lbs) of force frequently
and/or up to 8.9 kg (20 lbs) of force constantly.

Comparison of Ability Levels


The National Institute of Occupational Safety and Health (NIOSH) set standards for evaluation of Physical Demand
Capacity. These are used in both the Canadian National Occupational Classification system (NOC) and the American
Directory of Occupational Titles (DOT).
Frequent Weight
A worker’s demonstrated tolerance for frequent weight (F) is recognized as the weight at which they first report a
change or increase in symptoms or the first pain behavior. It is estimated that the worker can safely handle this
weight for up to 66% of their workday tolerance.
Occasional Weight
A worker’s demonstrated tolerance for occasional weight (O) is recognized as the maximum weight they are able
to lift, carry, or push/pull. It is estimated that the worker can safely handle this weight for up to 33% of their workday
tolerance.

(*Adapted from The Medical Disability Advisor, Presley Reed, M.D., LRP Publications; and from the National Occupation Classification)

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