Health Professional`s Progress Report (Form 26)

This version of the form is for REFERENCE ONLY and CANNOT BE PRINTED
26
Fax To:
416-344-4684
OR 1-888-313-7373
Section 37 of the Workplace Safety and Insurance Act authorizes you to release this information
to the WSIB. Please answer all questions in black ink or type and return by fax to (416) 344-4684
or 1-888-313-7373.
Health Professional's
Progress Report (Form 26)
Claim Number
Date of Incident (dd/mmm/yyyy)
Worker's name
When work injury/illness occurs, focus on return to usual activity including return to safe and appropriate work is best practice.
Most workers who experience soft tissue injury are able to remain at work.
Return to Work Information
1.
(dd/mmm/yyyy)
This worker can resume Regular duties.
Start date
This worker can begin Modified duties.
Start date
Are graduated hours required? If yes, please specify
(dd/mmm/yyyy)
Are graduated hours required? If yes, please specify
Pain should not be the only medical restriction. Is there any other reason this worker cannot return to work at this time?
Please provide details and expected return to work date:
2.
Please indicate the worker's functional abilities in relation to the workplace injury.
A. Full functional abilities
B. Some functional abilities
Able to
Not Able to
Able to
Bend/Twist
Climb
Kneel
Lift
Operate Heavy Equipment
Operate a Motor Vehicle
Not Able to
Push/Pull
Sit
Stand
Use of Public Transportation
Use of Upper Extremities
Walk
Other Limitations due to:
Environmental Conditions
Medication
Use of Protective Equipment
Additional comments on abilities (e.g. maximum repetitions, maximum weight, maximum time to be considered).
Clinical Information and Treatment Plan
3. Please indicate change in the patient's condition since last visit.
If worsening, provide details on the patient's condition:
Recovered
Improving
Worsening
Unchanged
4. Current diagnosis.
5. Are you aware of any pre-existing or other conditions/factors that would impact return to work or recovery?
If Yes, describe (e.g. psychosocial, medications).
6. Prognosis - Please select one of the following choices:
No
Partially recovered now, continuing to improve.
Full recovery not yet known.
Fully recovered now.
Partially recovered now and full recovery
is anticipated in approximately
Yes
Full recovery not expected.
weeks.
7. What is the current treatment plan (type of treatment, interventions, duration)?
Billing Section
Service Code
Health Professional Designation
Chiropractor
HST Registration No.
Physician
Physiotherapist
HST Amount Billed (if applicable)
$
Registered Nurse (Extended Class)
Your Invoice No.
Service Code
Service Date
dd
mmm
yyyy
ONHST
Health Professional Name (please print)
Address
Health Professional's Signature
Telephone
0896A (08/12)
WSIB Provider ID
26M
www.wsib.on.ca
Fax
26