Forms
The following forms and physician information
refer to the Forms section found in
Work-Related Low Back Pain “The New Paradigm”
Staff Forms
Patient Forms - Initial Visit
Special Note: Depending on the physician’s preference the next two questionnaires can either be completed by the injured worker before the patient is seen or the forms may be placed in the chart for the physician to complete or have the injured worker complete during the conclusion of the initial visit.
- Physical Demands Questionnaire - P-X
This questionnaire is completed only if the injured worker is not working, and the physician wishes to have the patient return to work with limitations that will require accommodation by the employer.
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- Occupational Factors Questionnaire - P-Y
This questionnaire is completed on the initial visit only if the injured worker is not working and the physician needs to know more detail about specific physical demands of the job.
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Patient Forms - Second Visit
- Pain Catastrophizing Questionnaire - Spouse - PCS-S
If the physician determines that this patient has "Pain Intolerance" issues, the injured worker is asked to bring his spouse on the second visit. On the second visit, the spouse is asked to complete this form because the doctor wants her to be an integral part of the patient’s "Medical Team."
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Two Week Re-Evaluation
Supplemental Patient Questionnaires
The following are additional questionnaires that may be used instead of others listed above. Should you prefer one of these forms, repeat at two weeks to make certain that you are capable of determining patient progress by using the same form(s).
- Pain Catastrophizing Scale Form - PCS-IEQ
Administered when it appears the injured worker is becoming a victim.
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- Modified Somatic Perception Questionnaire - IW-10
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- Beck's Depression Inventory Questionnaire
This questionnaire is similar to the Zung Depression questionnaire and may be used as a substitute.
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- Bournemouth Back Questionnaire
Some like this questionnaire because it contains a few psychometric questions that the Oswestry or the Roland Morris questionnaires do not contain.
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- Roland-Morris Disability Questionnaire
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- Dysfunctional Attitude Scale Questionnaire for Patients - DAS
This questionnaire is used to measure pervasive negative attitudes of a depressed person regarding self, the outside world, and the future. The DAS helps identify psychological strengths and vulnerabilities. The score for each of the seven categories results in a positive and negative outcome that may be used in conjunction with the patient's cognitive distortions. The categories are approval, love, achievement, perfectionism, entitlement, omnipotence, and autonomy. These results may provide a clearer understanding of how the patient will view events based on their thoughts presented in the list of cognitive distortions.
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Physician Forms
Return to Work Forms
These forms are used when the nurse case manager or vocational rehabilitation specialist are assisting the injured worker in returning to the job of injury or finding a new job within his physical limitations.
Physician Information
Calculating Patient Questionnaires
Home CBT, Desensitization, Activity, and Exercise Forms
- Definitions of Cognitive Distortions - DoCD
Cognitive means thoughts and distortions are ways our minds convince us of something that isn’t really true. These are problematic because they are inaccurate and reinforced by negative thinking which leads to unnecessary emotional responses. They are clinically used to help patients realize that their negative thoughts should be reconstructed in order to overcome their distortions of reality. Most patients quickly pick out their own cognitive distortions as they read through the definitions.
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- Interpreting the DAS Scores
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- Daily Record of Dysfunctional Thoughts Form - H-DDT
This document will show how the spouse and injured worker should complete the Triple-column technique form. Cognitive Distortions should be used to understand how to complete the triple-column form. This process is important. It helps the injured worker and his spouse recognize an event and the patient’s emotional response. The thoughts are negative automatic thoughts (NATS) that are typically caused by one or more of the cognitive distortions. The negative responses (thoughts) must be identified and reconstructed with a more rational response if the patient is going to change his automatic thoughts and emotional responses. Pain is the most significant event that triggers the NATs and emotions. This process is also used during the home activity and exercises, as well as, the in-office activity and exercises. When the efforts exceed the patient’s tolerance, and pain occurs, the patient is instructed to use this process. As the emotional response is managed and the thoughts restructured the pain level diminishes.
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- Triple-Column Technique Form - T-C-T
The first page of this form is an illustration that asked the injured worker to evaluate his thought and assign that thought to one of the cognitive distortions. As the patient and spouse read over the cognitive distortions, they will be able to identify the one(s) that apply and recreate a more rational response. The second page is a repeat of the first page, but all of the data fields are left blank for the patient and spouse to identify the NATs, emotions, and to change the thought to a more reasoned rational response.
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- Home Activity and Exercise Response Diary Form - H-A-E-R
The home activity and exercise program are designed to keep the injured worker active. The physician will check off those activities and exercises that he would like the injured worker to do. The injured worker is then asked to make a notation regarding discomfort after an activity or exercise, identify an emotional response, identify the negative automatic thought(s) and note the replacement thought(s).
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- Home Activity and Exercise Sheet Form - H-A-E-S
This form is used in conjunction with form (Home Activity & Exercise Response Diary (Form H-DDT)). The physician indicates a starting quota for each activity and exercises that should be done at home. The quota is either several repetitions or a length of time and should be slowly increased to the level that begins to elicit a small amount of discomfort. As the activity or exercise is increased the patient should be taught how to use the cognitive restructuring discussed in forms (Daily Record of Dysfunctional Thoughts (Form H-DDT)) and (Triple-column technique (Form T-C-T)).
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Additionally, methods of desensitization, discussed below, in relationship to (Home Stress Relief Practice Diary (Form H-S-P-D)). This process helps the patient develop the self-help skills necessary to self-manage the pain associated with increases that occur as a result of increasing activities of daily living, and functional skills required by his job. The physician will also indicate the times of day that the injured worker should perform each activity or exercise.
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- Home Stress Relief Exercises Form - H-S-R-E
The physician indicates a starting quota for each activity and exercises that he wants the patient to do at home. The quota is either several repetitions or a length of time and should be slowly increased to the level that begins to elicit a small amount of discomfort. The physician will also indicate the times of day that the injured worker should perform each activity or exercise.
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- Home Stress Relief Practice Diary Form - H-S-R-P-D
The activities listed in the left column are methods of relaxation and pain desensitization. The injured worker should test each one of these to determine the one that is most effective in reducing pain levels associated with increased activity and exercise.
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Chapter 8 Forms
(partial list related to initial contact with injured worker, employer, insurer, as well as, patient and physician forms related to return to work)
- Patient First Contact Form - APT-1
This form is used when the appointment is made to obtain important information related to the injured workers’ injury. Administratively the form gathers important information to assure proper handling of the workers’ compensation claim, as well as, identification of potential problems that may need to be cleared up before the injured workers’ first visit.
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- Employer's First Contact Form - E-1
After the appointment is made, the staff should use this form to gather additional information from the employer or insurer. The most important information to obtain is the injured workers’ job description, physical demands of the job, and the employer’s return to work policy. This information is necessary for the first visit to permit the physician to evaluate the patient and make a decision for the injured worker to return to work at a modified duty status. If the employer does not have this information, the staff should use the Dictionary of Occupational Titles and O*Net Occupational Search (when the employer has not created their own job descriptions and physical demands). The staff person who is assigned to the task of obtaining this information from a new patient’s employer should copy this link to their desktop computer for quick access when talking to the employer before the first visit.
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- Employer’s Job Description and Physical Demands Form - E-2
This form should be faxed to the employer requesting that the employer provide the information. As described above, the Dictionary of Occupational Titles can be used by your staff and provided to the employer or the employer can go online to obtain a job description. The employer can then provide a list of physical demands of the job.
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- Employer's Return-to-Work Policy Form - E-3
This form is sent to the employer to obtain information about job accommodation. After measuring physical limitations on the first visit, the physician can return the patient to work within his physical limitations. Thus, the injured worker is kept on the job and will improve more quickly. When the injured worker can return to modified duty without lost time from the workplace, it is a win for all stakeholders. The most important being the injured worker.
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- Employee’s Physical Demands Form - IW-8
This questionnaire is only used if the injured worker is not working.
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- Physician's RTW Form - P-2
At the conclusion of the first visit, the physician should complete this form spelling out limitations, but focusing on what the injured worker can do versus what he should not do. This helps the employer assign modified duty tasks that the injured worker is capable of performing. Additionally, it helps the injured worker understand what he is capable of doing.
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- Low Back Examination Form - P-3
This simple examination form provides tests that are typically used in each area of the spine and can be used as a guide. While some functional tests are included in this form, the physician should become familiar with the QCE examination and additionally focus on the functions related to the physical demands of the job.
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- DOA Office of Risk Management
(Forms from Louisiana Office of Workers’ Compensation)
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In full compliance with copyright laws, external
links are provided for some of these forms.
When we address "Copyright Infringement" and " "Fair Use".
Copyright Infringement Claim Form