Dwc Form Pr 3 – Fill Out and Use This PDF

STATE OF CALIFORNIA

Division of Workers’ Compensation

PRIMARY TREATING PHYSICIAN’S PERMANENT AND STATIONARY REPORT (PR-3)

This form is designed to be used by the primary treating physician to report the initial evaluation of permanent disability to the claims administrator. It should be completed if the patient has residual effects from the injury or may require future medical care. In such cases, it should be completed once the patient’s condition becomes permanent and stationary or has reached maximum medical improvement.

This form should not be used by a Qualified Medical Evaluator (QME) or Agreed Medical Evaluator (AME) to report a medical- legal evaluation.

Patient:

Last Name__________________________ Middle Initial ____ First Name ___________________Sex ____ Date of Birth ___________________

Address ______________________________________________City _______________________________State _____ Zip _________________

Occupation __________________________________ Social Security Number ____________________________ Phone No. _________________

Claims Administrator/Insurer:
Name _______________________________________________________________________		Phone Number ___________________________
Address ____________________________________________	City _____________________ State _______		Zip ______________________
Employer:
Name ________________________________________________________________________		Phone Number	_________________________
Address ____________________________________________	City ________________________ State _______ Zip ____________________

You must address each of the issues below. Use of the form below is optional. You may substitute or append a narrative report if you require additional space to adequately report on these issues.

Date of Injury________________ Last date ________________ Date of current __________________Permanent & __________________

Date

worked

Date

examination

Date

Stationary date

Date

Description of how injury/illness occurred (e.g. Hand caught in punch press; fell from height onto back; exposed 25 years ago to asbestos):

Patient’s Complaints:

DWC PR – 3 (Rev. 1/1/01)

STATE OF CALIFORNIA

Division of Workers’ Compensation

PRIMARY TREATING PHYSICIAN’S PERMANENT AND STATIONARY REPORT (PR-3)

Relevant Medical History:

Objective Findings:

Physical Examination: (Describe all relevant findings; include any specific measurements indicating atrophy, range of motion, strength, etc.; include bilateral measurements - injured/uninjured - for upper and lower extremity injuries.)

Diagnostic tests results (X-ray/Imaging/Laboratory/etc.)

Diagnoses (List each diagnosis; ICD-9 code must be included)		ICD-9
1.		______________________________________
2.		______________________________________
3.	__________________________________________________________________	______________________________________
4.	__________________________________________________________________	______________________________________

	Yes	No	Cannot determine
Did work cause or contribute to the injury or illness?	V	V	V

Apportionment:

Are there pre-existing impairments/disabilities that contribute to permanent disability?V V V If Yes, append narrative to describe cause and extent of pre-existing disability; describe

any documentation of pre-existing disability.

Can this patient now return to his/her usual occupation?	V	V	V
If not, can the patient perform another line of work?	V	V	V

DWC Form PR-3 (Rev. 1/1/01)

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STATE OF CALIFORNIA

Division of Workers’ Compensation

PRIMARY TREATING PHYSICIAN’S PERMANENT AND STATIONARY REPORT (PR-3)

Subjective Findings: Provide your professional assessment of the subjective factors of disability, based on your evaluation of the patient’s complaints, your examination, and other findings. List specific symptoms (e.g. pain right wrist) and their frequency, severity, and/or precipitating activity using the following definitions:

Severity: Minimal pain (Min) - an annoyance, causes no handicap in performance. Slight pain (Slt) - tolerable, causes some handicap in performance of the activity precipitating pain. Moderate pain (Mod) - tolerable, causes marked handicap in the performance of the activity precipitating pain. Severe pain (Sev) - precludes performance of the activity precipitating pain.

Frequency: Occasional (Occ) - occurs roughly one fourth of the time. Intermittent (Int) - occurs roughly one half of the time. Frequent (Fre) - occurs roughly three fourths of the time. Constant (Con) - occurs roughly 90 to 100% of time.

Precipitating activity: Precipitating activity gives a sense of how often a pain is felt and thus is often provided in lieu of frequency, e.g. slight pain in back on heavy lifting, or slight-to-moderate pain in knee when standing or walking more than six hours per day. Can be used in conjunction with frequency if pain is less than constant while engaging in the precipitating activity. For example, intermittent slight pain on bending would be felt approximately 50% of time while actually engaged in bending.

Symptom

Frequency

Severity

Precipitating

(Mark X at any spot)

(Mark X at any spot.)

Activity

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Occ

Int

Fre

Con

Min

Slt

Mod

Sev

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Occ

Int

Fre

Con

Min

Slt

Mod

Sev

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Occ

Int

Fre

Con

Min

Slt

Mod

Sev

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Occ

Int

Fre

Con

Min

Slt

Mod

Sev

	Yes	No	Cannot determine
Pre-Injury Capacity Are there any activities at home or at work that the patient cannot do	V	V	V
as well now as could be done prior to this injury or illness?

If yes, please describe pre-injury capacity and current capacity (e.g. used to regularly lift 30 lb. child, now can only lift 10 lbs.; could sit for 2 hours, now can only sit for 15 mins.)

1.

2.

3.

4.

DWC Form PR-3 (Rev. 1/1/01)

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STATE OF CALIFORNIA

Division of Workers’ Compensation

PRIMARY TREATING PHYSICIAN’S PERMANENT AND STATIONARY REPORT (PR-3)

Preclusions/Work Restrictions
	Yes	No	Cannot determine
Are there any activities the patient cannot do?	V	V	V

If yes, please describe all preclusions or restrictions related to work activities (e.g. no lifting more than 10 lbs. above shoulders; must use splint; keyboard only 45 mins. per hour; must have sit/stand workstation; no repeated bending). Include restrictions which may not be relevant to current job but may affect future efforts to find work on the open labor market (e.g. include lifting restriction even if current job requires no lifting; include limits on repetitive hand movements even if current job requires none).

1.

2.

3.

4.

5.

6.

Future Medical Treatment: Describe any medical treatment related to this injury that you believe the patient may require in the future. Include medications, surgery, physical medicine services, durable equipment, etc.

Comments:

DWC Form PR-3 (Rev. 1/1/01)

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STATE OF CALIFORNIA

Division of Workers’ Compensation

PRIMARY TREATING PHYSICIAN’S PERMANENT AND STATIONARY REPORT (PR-3)

List any other physicians who contributed information used in this report:
A.	Name ______________________________________________		Specialty ________________________________________________
B.	Name ______________________________________________		Specialty ________________________________________________
C.	Name ______________________________________________		Specialty ________________________________________________
List information you reviewed in preparing this report, or relied upon for the formulation of your medical opinions:
Medical Records		Personnel Records

Written Job Description

Any other, please describe:

Primary Treating Physician (original signature, do not stamp)

I declare under penalty of perjury that this report is true and correct to the best of my knowledge, and that I have not violated Labor Code §139.3.

Signature :						Cal. Lic. # : __________________________ _
Executed at :						Date: __________________________________
		(County and State)
Name (Printed) :						Specialty: _______________________________
Address : _________________________________________			City: ___________________ State: __________Zip : _________
Telephone: ______________________________________

DWC Form PR-3 (Rev. 1/1/01)

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