Name (please print):
Date symptoms first appeared
Date patient’s condition first prevented them from working
Date of first visit for treatment or consultation
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1. Please PRINT.
2. Part 1 to be completed by patient.
3. Part 2 to be completed by physician.
4. Any charge for completion of this form is the patient’s responsibility.
Part 1: Patient Authorization
Telephone Number (including area code):
I authorize my healthcare or rehabilitation provider to disclose my personal information, including my medical and health information
and including consultation reports, to Canada Life Life for the purpose of investigating and assessing my claim(s), administering
coverage(s) that I may have with Canada Life Life and administering the group benefits plan. Medical and health information
excludes genetic test results.
I acknowledge that the personal information is needed by Canada Life Life for the purposes stated above. I acknowledge that my
consent enables Canada Life Life to process my claim(s) and refusing to consent may result in delay or denial of my claim(s).
This consent may be revoked by me at any time by sending a written instruction.
I confirm that a photocopy or electronic copy of this authorization shall be as valid as the original.
Part 2: Attending Physician’s Statement
1. Diagnosis (please provide copies of all relevant clinical notes, test results and consultation reports. Do not provide
genetic test results.)
Has patient ever had the same or a similar condition?
Yes No Unknown
Is condition a result of an injury due to an accident? Yes No
Is condition due to injury or sickness arising out of patient’s employment? Yes No Unknown
If yes, have Workers’ Compensation Board/CSST forms been completed? Yes No
Frequency of visits: Weekly Monthly Other
Date of birth:
Date of latest visit:
Date of hospital inpatient admission:
Date of discharge:
Date of hospital outpatient admission:
Year Month Day
Street & Number
City Province Postal Code
( )
Patient’s Signature Date
Year Month Day
Year Month Day
Year Month Day
If yes, state when and describe:
If yes, please describe.
Current height Current weight Weight loss / gain to date
Year Month Day
Year Month Day
Year Month Day
Year Month Day
Name of hospital:
Other treating physicians:
Pending referrals to specialists:
2. Please outline all objective studies performed / scheduled (X-rays, laboratory data, C.T. scans, etc.) and attach copies of each
Date Procedure Results
3. Please indicate the nature and severity of the patient’s symptoms and signs.
Please specify location(s) and physical findings Severe Moderate Mild Absent
Muscle Spasm
Muscle Atrophy
Loss of Tendon Reflexes
Sensory Change
Motor Deficit
Straight Leg Raising Limitation
Range of Motion Limitation
Other (specify)
If Arthritic Condition: In Remission Continuously Active Stable
Seasonally Active Intermittently Active Progressive
If Fracture: Closed Depressed Open Compressed Comminuted
4. Treatment
Is patient compliant with prescribed measures?
Yes No
5. Limitations and Restrictions
Hours at one time
<1 1-2 2-4 4-6 6-8
Total hours during day
<1 1-2 2-4 4-6 6-8
No restriction
Walk No restriction
Walk on uneven surfaces Yes No
Sit No restriction
Drive No restriction
This patient can lift/carry a maximum of:
No restriction Repetitively - how much?
Occasionally - how much?
Please indicate in the space provided if this patient is able to perform the following actions:
(Frequently (F), Occasionally (O) or Not at all (N):)
kgs 0 5 9 14 18 23 27 32 36 41+
lbs 0 10 20 30 40 50 60 70 80 90+
Medications (dose / frequency / date prescribed):
Physiotherapy (type, frequency, dates):
Surgery date (past): Year Month Day Type:
Surgery date (future): Year Month Day Type:
Other treatment:
If No, please explain:
Drive Bend Squat Kneel Climb Reach (above shoulders) Reach (below shoulders)
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6. Prognosis / Return to work plans:
Assessment and treatment are complicated by: (please select and explain in the space provided below)
Significant emotional or behavioral disorder such as depression, anxiety, etc.
Exaggeration, inconsistent findings, subjective complaints out of proportion to objective findings, bizarre or contradictory
Work-related issues (please describe if known)
Substance abuse
Other (please describe)
Is patient a suitable candidate for medical rehabilitation services?
Yes No
Is patient a suitable candidate for vocational rehabilitation? Yes No
Notice to Physician
The information in this statement will be kept in a life, health, or disability benefits file with the insurer or plan administrator and might be accessible
by the patient or third parties to whom access has been granted or those authorized by law. By providing the information I consent to such unedited
release of any information contained herein. 1-855-755-6729
Attending Physician (please print) Certified Specialty Physician’s Stamp
Address (Street, City, Province, Postal Code)
Telephone # (+ Area Code) Fax # (+ Area Code)
Email Address
Signature Date Signed (dd/mm/yyyy)
Prognosis for recovery:
Expected date patient will return to their own occupation: Year Month Day
If unknown, please indicate the next follow up date: Year Month Day
If your patient is unable to return to their regular occupation, please specify when and under what circumstances they could
return to work (eg. modified duties, gradual return to work).
If yes to either of the above, please specify:
Is there any other information you wish to add that will give us a better understanding of your patient’s condition or treatment