MEDICAL PROGRESS REPORT AND CHRONIC MEDICINE CONTINUATION
APPLICANT DETAILS
Surname:
Initials:
Date of birth:
Gender:
Occupation:
RMA Claim No:
Industry No:
Date of Accident:
Tel (W):
CELL:
Employer:
Tel (H):
CLINICAL DETAILS
Injured part and description of disability:
EVALUATION OF PAIN
Type of pain: (please indicate with an X)
Neurogenic:
Mechanical:
Degenerative:
Psychogenic:
Muscle spasm:
Fibromialgia
Other (please specify):
Objective evaluation of pain: (please indicate with an X)
Mild:
Moderate:
Severe:
Continuous duration of chronic medication:
Restrictive:
months/years
ALTERNATIVES AND ADJUVANTS USED FOR PAIN MANAGEMENT
(Please indicate with an X)
Lifestyle changes:
Physiotherapy:
Nerve block:
Arthroplasty:
Psychotherapy:
Acupuncture:
Other (please specify):
PRESCRIBED CHRONIC MEDICINE FOR INJURY RELATED CONDITION:
Injury related problem
ICD10
Medication prescribed
Dosage
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GENERAL PRINCIPLES FOR PRESCRIBING ONGOING CHRONIC MEDICINE TO INJURED WORKERS
1. Chronic medicine or treatment beyond two years for work-related injuries must be assisting to reduce permanent disability or
maintaining the disability at its current level.
2. The treating doctor must motivate any further treatment by submitting a medical report.
3. Ongoing treatment should be confined mainly to analgesics and anti-inflammatories to reduce pain.
4. Pre-authorisation is required for the prescription and issuing of chronic medication.
PRESCRIBING DOCTOR’S DETAILS
Surname:
Initials:
Practice No:
Email:
Tel:
Cell:
Address:
Code:
Signature:
Date:
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