NAME: First Last Panel QME DATE: 00/00/2022 DI
DOI: 00/00/0000; CT 00/00/0000– 00/00/0000 Page 1 AVEGAIL SAMONTE
NOTE: No cover letter available during the history call.
BODY PARTS IN THE COVER LETTER:
BODY PARTS IN THE EAMS:
CURRENT COMPLAINTS:
BODY PART:
In general, the examinee’s complaints are alleviated with NONE
ACTIVITIES OF DAILY LIVING: NONE
HISTORY OF INJURY AS RELATED BY THE EXAMINEE:
The examinee is a 00-year-old, right-handed male, born ON __ who has filed a claim of injury to
the body while working as a ___ for Praxair, Inc. on ___
SI MECHANISM OF INJURY: Mr. name reports that on __ at around ___during the course of
his employment, he was working ___. The examinee states his co-worker, witnessed the incident.
The examinee was ___to finish his shift and was ___to return to work the next day. The incident
was reported to his employer ___and a report was filed.
INITIAL TREATMENT: ___
SUBSEQUENT TREATMENT: ___.
___
The examinee specifically denies receiving treatments other than stated above.
– NO CTP
JOB DESCRIPTION:
___: The examinee worked ___hours a week. His job duties ___K. Physically, he was required
to ___
OCCUPATIONAL HISTORY:
The examinee began employment with ___ IN/ON ___. The examinee IS ___
Employers:
NAME: First Last Panel QME DATE: 00/00/2022 DI
DOI: 00/00/0000; CT 00/00/0000– 00/00/0000 Page 2 AVEGAIL SAMONTE
NOTE: No cover letter available during the history call.
BODY PARTS IN THE COVER LETTER:
BODY PARTS IN THE EAMS:
1___
2. NONE
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: Family history is unremarkable.
SYSTEM REVIEW: System review is unremarkable.
ENT: No hearing loss or difficulty swallowing.
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 or 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:
NAME: First Last Panel QME DATE: 00/00/2022 DI
DOI: 00/00/0000; CT 00/00/0000– 00/00/0000 Page 3 AVEGAIL SAMONTE
NOTE: No cover letter available during the history call.
BODY PARTS IN THE COVER LETTER:
BODY PARTS IN THE EAMS:
HABITS: Tobacco: None.
Caffeine: The examinee consumes one cup of coffee per
day.
Alcohol: The examinee consumes 3-8 beer WEEKLY.
MARRIAGE/CHILDREN: He is ___and has 03 children, ages ___
RECREATIONAL ACTIVITIES: He enjoyed playing ___.
He She has completed * years of education.
SERVICE-RELATED
DISABILITY: None.
Que tenga un buen dia/feliz tarde.
