Fillable Musculoskeletal Program of Care (MSKPOC) Initial Assessment Report

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Musculoskeletal Program of Care (MSKPOC) Initial Assessment Report

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The Musculoskeletal Program of Care (MSKPOC) Initial Assessment Report form is 2 pages long and contains:

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  • 111 other fields

Country of origin: CANADA
File type: PDF

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Mail to:
200 Front Street W.
Toronto ON
M5V 3J1
Fax to:
416-344-4684 or
1-888-313-7373
Musculoskeletal
Program of Care (MSKPOC)
Initial Assessment Report
Claim Number
For an injury to: (select one)
Upper body (excluding the shoulder)
Lower body (excluding the lower back)
Please PRINT in black ink.
A. Worker & Employer Information Section
Init.
Last Name
First Name
Address (no. street, apt.)
City/Town Postal Code Telephone
Prov.
( )
Date of Birth (dd/mmm/yyyy)
Date of Injury (dd/mmm/yyyy)
Sex
F
M
Telephone No.
Supervisor/Contact Name
Employer Name
( )
Worker's Current Job Title/Occupation
Length of time
in current job:
months years
Employment status at time of assessment:
Full time OR Part time Not working
Please ask the worker before assessment:
If not working, how long do you think you
will be off work?
Regular duties OR Modified duties
Regular hours OR Modified hours
days
B. Health Professional Information
Chiropractor Physiotherapist Other, please specify:
Facility Name
Health Professional Name (please print)
City/Town Postal Code
Address (no. street, apt.) Prov.
Telephone Date of initial assessment (dd/mmm/yyyy)
( )
C. Clinical Information
2. Date of referral (dd/mmm/yyyy)
1. Name of the referring health professional (if applicable)
3. Worker’s history of injury:
4. Area(s) of injury:
5. Pertinent Clinical Signs:
6. Working Diagnosis:
7. Additional information:
2345A (01/14) Page 1 of 2
visit our website at:
www.wsib.on.ca
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Musculoskeletal
Program of Care (MSKPOC)
Initial Assessment Report
Worker's Last Name Worker's First Name
Date of Birth (dd/mmm/yyyy) Date of Injury (dd/mmm/yyyy)
Claim Number
D. Functional Information
Administer and record the scores for the Patient-Specific Functional Scale (PSFS) for 3-5 functional activities at least 2 of which are
work-related. The PSFS is available on the WSIB web site at www.wsib.on.ca.
Relevant Physical
Demands/Functional
Requirements
Clinician’s Assessment
of Current Ability
Functional Activity Score
E.g. Lift from floor level Lift 30 lb box from floor level, using
both hands.
Can lift 10 lbs from 8” elevation to
hip level.
3/10
/10
1.
/10
2.
/10
3.
4.
/10
/10
5.
Total: Divide the total score by the
number of activities (minimum of 3
activities)
/10
Have you identified any factors that may delay recovery or Return to Work?
No
Yes
If yes, please describe:
E. Treatment Plan & Return to Work Recommendations
1. Considering your assessment findings, what are your recommendations for work activities?
Regular duties
Yes No If no, enter expected date (dd/mmm/yyyy)
If no, enter expected date (dd/mmm/yyyy)
Modified duties Yes No
Regular hours Yes No If no, enter expected date (dd/mmm/yyyy)
Modified hours
Yes No
If no, enter expected date (dd/mmm/yyyy)
2. Please estimate the frequency of visits that is appropriate for this worker: ____ per week
3. Please estimate the length of care that will be required for this worker: ____ weeks
Date (dd/mmm/yyyy)
Health Professional Signature
2345A2 Page 2 of 2
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Musculoskeletal Program of Care (MSKPOC) Initial Assessment Report

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Completed 11 February 2021

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