NAME: First Last Panel QME DATE: 00/00/2022 DI
DOI: 00/00/0000; CT 00/00/0000– 00/00/0000 Page 1 AVEGAIL
ALCANTARA
NOTE: No cover letter available during the history call.
BODY PARTS IN THE COVER LETTER:
BODY PARTS IN THE EAMS:
CURRENT COMPLAINTS:
___________: The examinee complains of PAIN pain in the ____ that is ____. The pain
radiates/does not radiates to her _______. The examinee rates the pain as ____ out of 10 on a
pain scale of 1 to 10. The symptoms are aggravated with ______. The symptoms are alleviated
with _____.
In general, the examinee’s complaints are alleviated with______
ACTIVITIES OF DAILY LIVING: The examinee ___________
HISTORY OF INJURY AS RELATED BY THE EXAMINEE:
The examinee is a 00-year-old, right-hand dominant female, born ON ____ who has filed a claim
of injury to the body while working as a _______ for ____. on ______.
SI MECHANISM OF INJURY: Ms. name reports that on ---- at around ---, during the course of
her employment, she was working _________ The examinee states her co-worker, witnessed the
incident. The examinee was _________ to finish her shift and was unable to return to work the
next day. The incident was reported to her employer on _________ and a report was filed / but
no report was filed/
INITIAL TREATMENT:
SUBSEQUENT TREATMENT:
The examinee specifically denies receiving treatments other than stated above.
She continues under the care of ____ in _____. She was last evaluated _______
JOB DESCRIPTION:
_________: The examinee worked 40 hours a week. Her job duties consisted of ______.
Physically, she was required to (_______).
NAME: First Last Panel QME DATE: 00/00/2022 DI
DOI: 00/00/0000; CT 00/00/0000– 00/00/0000 Page 2 AVEGAIL
ALCANTARA
NOTE: No cover letter available during the history call.
BODY PARTS IN THE COVER LETTER:
BODY PARTS IN THE EAMS:
OCCUPATIONAL HISTORY:
The examinee began employment with ____. on _____. The examinee last worked on _____
Employers:
1. COMPANY IN____ (JOB TITLE): YEARS
2. COMPANY IN____ (JOB TITLE): YEARS
PREVIOUS INJURIES:
INDUSTRIAL: NONE
NONINDUSTRIAL: NONE
MVA: None
SUBSEQUENT INJURIES:
INDUSTRIAL: None.
NONINDUSTRIAL: None.
PAST MEDICAL HISTORY:
PREVIOUS SYMPTOMS/
TREATMENT TO AFFECTED AREAS: None.
MEDICAL ILLNESSES: None
SURGERIES: None
ALLERGIES: No known allergies.
CURRENT MEDICATIONS:NONE
FAMILY HISTORY: unremarkable
SYSTEM REVIEW: System review is unremarkable.
ENT: No hearing loss and difficulty swallowing.
NAME: First Last Panel QME DATE: 00/00/2022 DI
DOI: 00/00/0000; CT 00/00/0000– 00/00/0000 Page 3 AVEGAIL
ALCANTARA
NOTE: No cover letter available during the history call.
BODY PARTS IN THE COVER LETTER:
BODY PARTS IN THE EAMS:
Endocrine: No known thyroid disease or heat/cold intolerance.
Skin: No new rashes or skin lesions.
Respiratory: No wheezing or asthma problems.
Cardiovascular: No chest pain and palpitations.
GI: No abdominal pain, nausea, gastritis, constipation, diarrhea,
or vomiting.
Neurological: No fainting spells, loss of consciousness, dizziness,
blackouts, memory loss, or seizures.
SOCIAL HISTORY:
HABITS: Tobacco: None.
Caffeine: The examinee consumes one cup of coffee per
day.
Alcohol: None.
MARRIAGE/CHILDREN: She is ___ and has ___ children, ages __
RECREATIONAL ACTIVITIES: She enjoys/enjoyed____
SERVICE-RELATED
DISABILITY: None.
Que tenga un buen dia/feliz tarde.
