Form 1048 Aps O – Fill Out and Use This PDF

Ins tructions

1 . Pleas e PR INT.

2 . Part 1 to be completed by patient.

3 . Part 2 to be completed by phys ician.

4. Any charge for completing this form is the patient’s responsibility.

Attending Physician’s Statement For Disability Benefits

Addres s (number, s treet, city, province, pos tal code)

I certify that the above statements are true and I hereby authorize The Canada Life Assurance Company and its authorized agents, including its legal representatives and investigators to obtain, receive, examine, copy and disclose any records or knowledge of me or my health, INCLUDING CONSULTATION REPORTS, from, or give to, any employer, physician, medical practitioner, hospital, clinic, attorney, investigative agency, insurance company and insurance support organization.

The purpose for which this information is collected is: i) to adjudicate my claim, ii) for the employer’s and policyholder’s statistical purposes, and iii) for whatever purposes the employer, policyholder and insurer so require.

A photographic copy of this authorization shall be as valid as the original. I hereby authorize the use of my Social Insurance Number for the administration of the benefits under this group policy.

Part 2: Attending Physician’s Questionnaire

1.DIAGNOSIS OF PRESENT CONDITION

Primary __________________________________________________________________________________________________________________________

Secondary _______________________________________________________________________________________________________________________

Has patient had same or similar condition in the past?
Yes No	If “Yes”, provide date(s) (day, month, yea r)	____ /____ /____	____ /____ /____	____ /____ /____
Date first seen ____ /____ /____ Date last seen____ /____ /____ Frequency of visits: Weekly				Monthly Other _____________________

Other treating physicians ___________________________________________________________________________________________________________

2.SYMPTOMS

	Pain in the (cervical, thoracic, lumbosacral) area		Stiffness or impaired range of motion
	(circle one or more)
	Subjective weakness or incoordination		Parasthesias or sensory disturbance in radicular or dermatomal pattern in the
			(arms(s), leg(s), trunk) (circle one or more)

Other (please specify) __________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

3.PHYSICAL FINDINGS

Distinct muscle spasm

Loss or distortion of normal spine curves

Neurological deficits: Power		Yes		No	If yes, explain _____________________________________________________________
Sensory Loss		Yes		No	If yes, explain _____________________________________________________________
Reflexes		Yes		No	If yes, explain _____________________________________________________________

Specific reliable and reproducible signs (please list) ________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Limitation of movement:
Forward flexion ________ degrees	Rotation ________ degrees	Lateral flexion ________ degrees	SLR ________ degrees

Limitations preventing return to work _______________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

4.TREATMENT

Medication: (dose/frequency/date) __________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Physiotherapy (type/frequency/date) _________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Please specify if done in clinic, hospital or home ______________________________________________________________________________________

Surgery Date (past): Day _____ Month _____ Year_____ Type: ________________________________________________________________________

Surgery Date (future): Day _____ Month _____ Year _____ Type: _______________________________________________________________________

1048 APS-O 11/05

5. RESULTS OF LABORATORY TESTS		Dates
X-rays	____________________________________________________________________________________	____ /____ /____	____ /____ /____
Cat Scan/MRI ____________________________________________________________________________		____ /____ /____	____ /____ /____
EMG Studies ______________________________________________________________________________		____ /____ /____	____ /____ /____
Other	____________________________________________________________________________________	____ /____ /____	____ /____ /____
Is patient compliant with prescribed measures? Yes No

PLEASE ATTACH COPIES OF RELEVANT TEST RESULTS

6.RESTRICTIONS AND LIMITATIONS

			Total hours
Functional capacity:	SITTING	8	7	6	5	4	3	2	1	_____________________________________________________________Other
	STANDING	8	7	6	5	4	3	2	1	_____________________________________________________________Other
	WALKING	8	7	6	5	4	3	2	1	_____________________________________________________________Other

What specific factors, if any, interfere with the patient’s ability to sit, stand or walk? _______________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

What devices might improve the patient’s ability to sit, stand or walk? ___________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

	Patient is able to:	Yes/no		Frequency		Duration
	Drive
	Crouch
	Balance
	Bend
	Twist
	Stoop
	Kneel
	Squat
	Climb Stairs
	Reach at shoulder level
	Reach above shoulder level
	Reach below shoulder level

7.PROGNOSIS

When do you anticipate the patient can return to work? ____ /____ /____

Own occupation: ____ /____ /____	Any occupation: ____ /____ /____	Or, if unable to determine, follow-up in _______ months
Is there any restriction you would like to see placed on patient’s return to work?		Yes No Please comment ________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Assessment and treatment are complicated by:

Significant emotional or behavioral disorder such as depression, anxiety, etc.

Exaggeration, inconsistent findings, subjective complaints out of proportion to objective findings, bizarre or contradictory observations

Work-related issues (please describe if known)_____________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Other (please describe) _________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Rehabilitation:	a) Is patient a suitable candidate for medical rehabilitation services?		Yes		No
	b) Is patient a suitable candidate for vocational rehabilitation?		Yes		No

c)If yes, please specify _________________________________________________________________________________________

______________________________________________________________________________________________________________

Additional comments ______________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Name of attending physician (pleas e print)	Specialty	Telephone no. (including area code)
		(	)	—
Address (number, s treet, city, province, pos tal code)		Fax no. (including area code)
		(	)	—

Submit to: The Canada Life Assurance Company, Group Creditor Disability/Life Claims Department 330 University Avenue, Toronto ON M5G 1R8

Telephone (416) 597-1440 Toll free no. 1-800-387-4492 Fax no. (416) 552-6557