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.
Use the worksheet with the source records
- Enter dates from the notice, medical record, payment record, or message instead of memory.
- Leave an item blank when it is unknown; do not guess to complete the page.
- Keep a private copy and update it after a new notice, appointment, payment, or work-status change.
- Bring the worksheet and the supporting documents to an agency call or lawyer consultation.