Initial Assessment Worksheet
Claimant: Jane Smith Claim No: Claim Number
DOB: 20/08/1972 Date of Referral: 21/02/2022
Date of Injury: 15, Aug, 2021 Injury: Right shoulder labral
tear/impingement
syndrome.
Pre Injury Wage 84,000p.a Power Date of Assessment: 21/03/2022
Rate: Engineer
☐ Explanation of referral and role of rehabilitation
☐ WorkCover information brochure provided
☐ How We Handle Your Personal Information pamphlet provided
☐ Hierarchy of RTW discussed
☐ Information Consent form explained and signed.
☐ Provision of Consultant business card/APM contact details
History of Injury .Mr. Larry Turner got a pain in his right shoulder after pulling down a level of power lines to
descend. He continued to work the next day as the pain subsided but it worsened after that, so he decided to
go to his supervisor. He was then sent to Dr. Virginie, his physiotherapist. Finally, he was sent to the hospital
and was diagnosed with right shoulder labral tear and impingement syndrome. After that, Mr. Turner was sent
for the surgery on the 15th, Oct, 2021. After that, he started working on rehabilitation in Vinnie Hospital.
Mr Turner reported that he was working on a line on Aug. 15, 2021 when he pulled a lever and felt his right
shoulder “pop,” followed by an immediate onset of excruciating pain which subsided into a dull ache. Mr Turner
reported that he thought it had “popped back in” and so attempted to continue throughout the day. However, the
pain increased in intensity throughout the day, so he reported the injury to his supervisor who sent him
immediately to the hospital for medical
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Previous treatment and medical investigations
Date Treatment or Medical Outcome and Findings
Appointment
15, Oct, Surgery – right shoulder Good
2021 arthroscopy Surgical intervention
Right shoulder arthroscopy
repair, debridement of labral tear,
and subacromial decompression
Oct, 2021 – Physiotherapy post op Working on Active Range of Motion and
Jan, 2022 strengthening
CURRENT STATUS
Return to Work
At work:
Same Employer Different Employer
Duties Current duties:
Pre-injury duties
Suitable duties
Hours Current hours:
Pre-injury hours hours per day
days per week
Reduced hours
OR
Not at work
Reason: on rehabilitation. Mr. Turner is keen on return to work.
Reason: Signed off by consultant until March 31, 2022
Current Medical Certification
Name of Medical Practitioner: Mr. Fisher ; Consultant orthopaedic surgeon
Certificate Period: From: Oct 2021
To: March 2022
Currents Medications:
Nurofen as required, multivitamins and fish oil
Functional status :
Mr Turner reported that he can complete all activities of daily living (personal care, domestics, etc.)
independently, including light yard work without any obvious limitations. He did report some difficulty with
getting the plates and bowls out from the lower cupboard with his right arm. Mr Turner reported he can walk
without limitations for 5-7kms and is keeping fit and healthy.
Psychosocial status:
Mr Turner has a supportive family but reports that his wife is anxious about his return to work. Mr Turner also
reported that he is anxious for the injury to occur again. Mr Turner reported he enjoys his work and has a good
relationship with his colleagues and supervisor. It is recommended that a Psychosocial Flags assessment be
completed to identify any flags.
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Current Symptoms difficulties in getting bowls and plates out of the cupboard with his right hand. Get twinges
of pain throughout the day, extended arm reach is struggling. Mr Turner reports difficulty reaching with his right
shoulder and arm and has reported some difficulty sleeping on his right side. Mr Turner reported that he
currently experiences twinges of pain in the right shoulder and these tend to get worse in the afternoon. He
reported the pain is generally manageable at a 2/10 but can increase to a 4/10
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Visual Analogue Scale
No pain |__________2-4________________________________________| Worst possible pain (Ambulance
required) 0 5 10
Self-reported functional tolerances
Sitting: Able to sit for a full day’s work (appropriate breaks)
Standing: reported would be able to stand for 2-3 hours comfortably
Walking: 5-7km daily, can push to 10km
Squatting Yes (Reported yes)
Kneeling Yes – no concerns
Lifting: Floor to waist Reported no concerns
Waist to waist Reported no concerns
Waist to shoulder Unable to manage with right shoulder
Waist to overhead Unable to manage with right shoulder
Carrying • Bilateral: / Distance: Up to metres reported able to carry shopping
50m
• Unilateral: / Distance: Up to metres: Struggle over a big distance
with right arm. up to 50m – with left arm taking the heavy shopping
Active Range of 4/5
Movement: Reduced range of motion in the right arm. Occ Rehab Counsellor to
follow up with report from treating Physiotherapist as well as Functional
Capacity Evaluation
Primary triggers Lifting over his head or shoulder, and repetitive
for onset of movements
symptoms:
Overhead lifting, overhead work, repetitive movements at shoulder
height on the right side and movements in extended right arm reach
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APPENDIX 1: WORK HISTORY
EDUCATION HISTORY
Education Duration/Year Completed
High school Year 12
Qualifications - Course Year Completed
Excel masterclasse, TAFE Not known
Landscaping level 1 UNKNOWN
Current Tickets and Licenses Year Completed
Apprenticeship with Energyprovider UNKNOWN
Forklift Licence UNKNOWN
EMPLOYMENT HISTORY AND EXPERIENCE
Job Title and Company Description of duties Dates of
Employment
Bank • Junior teller: admin type tasks : Approx +15
counting money, inputting data in years ago
the computer and spreadsheets,
customer service.
Energy provider •Power Engineer Working on overhead power Past 15
lines, pulling, reaching, climbing ladders, using years
levers and pulley systems, elevated work
Plan:
Document here what needs to be done next or what the discussed plan was.
Fill out the FCE report, and contact Jimmy, the physiotherapist.
1) Contact Employer to get an understanding of work expectations. 2) Functional Capacity Evaluation with
return-to-work plan 3) Psychosocial flags assessment 4) Contact Physiotherapist for
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