Use this as a private worksheet
Prepare accurate records and job-duty information for an independent medical examination. This is not an official agency or court form.
Before the exam
- ☐ Appointment notice: ______________________________
- ☐ Medication list: ______________________________
- ☐ Prior relevant records: ______________________________
- ☐ Current job description: ______________________________
Accuracy
- ☐ Symptom timeline: ______________________________
- ☐ Prior injuries/conditions: ______________________________
- ☐ Current restrictions: ______________________________
- ☐ Treatment already received: ______________________________
After the exam
- ☐ Save report when received: ______________________________
- ☐ Compare factual history: ______________________________
- ☐ Compare work duties: ______________________________
- ☐ List objective errors to discuss with counsel/provider: ______________________________
Privacy reminder
Keep sensitive medical, wage, claim-number, and employment information private. Share it only with appropriate official agencies, licensed professionals, insurers, treating providers, or other people who legitimately need it for the claim.