Initial Assessment Worksheet

Claimant: Insert name here Claim No: Claim Number

DOB: Client DOB Date of Referral:

Date of Injury: InjuryDate Injury: Brief description of injury

Pre Injury Wage Date of Assessment:

Rate:

☐ Explanation of referral and role of rehabilitation

☐ WorkCover information brochure provided
☐ How We Handle Your Personal Information pamphlet provided
☐ Hierarchy of RTW discussed
☐ Information Consent form explained and signed.
☐ Provision of Consultant business card/APM contact details

History of Injury

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Previous treatment and medical investigations
Date Treatment or Medical Outcome and Findings
Appointment

CURRENT STATUS
Return to Work
At work:
Same Employer Different Employer

Duties Current duties:

Pre-injury duties

Suitable duties

Hours Current hours:

Pre-injury hours hours per day

days per week
Reduced hours

OR
Not at work
Reason:
Current Medical Certification
Name of Medical Practitioner:

Certificate Period: From:

To:

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Current Symptoms

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Visual Analogue Scale

No pain |__________________________________________________| Worst possible pain (Ambulance

required) 0 5 10

Self-reported functional tolerances

Sitting: How long can they sit down on a chair?

Standing: How long can they comfortably stand?

Walking: How far can they walk?

Squatting Can they squat?

Kneeling Can they kneel? How long can they manage?

Lifting: Floor to waist Any difficulties?

Waist to waist

Waist to shoulder

Waist to overhead

Carrying • Bilateral: / Distance: Up to metres

• Unilateral: / Distance: Up to metres
Active Range of
Movement:

Primary triggers What makes the symptoms worse?

for onset of Is there a particular task or movements?
symptoms:

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APPENDIX 1: WORK HISTORY
EDUCATION HISTORY
Education Duration/Year Completed

Qualifications - Course Year Completed

Current Tickets and Licenses Year Completed

EMPLOYMENT HISTORY AND EXPERIENCE
Job Title and Company Description of duties Dates of
Employment

Plan:

Document here what needs to be done next or what the discussed plan was.
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