Impairment Rating Requirements
If you elect to file an impairment claim, you will be required to provide Activities of Daily Living (ADL), along with the required medical records dated preferably within the last 12 months.
The ADLs must be provided by your Specialist Physician, Family Practitioner or Primary Physician in a letter or should be noted in your medical records (for example, History and Physical Examination) in order for the impairment rating to be performed. For your convenience, please take the attached sample ADL Questionnaire to your treating physician for his/her completion. Please remember your medical records and diagnostic examinations must include your current treatments and prescribed medications. This information should be dated within the last 12 months. However, if you have no additional medical records to provide, please inform our office in writing, so that we can proceed with your impairment claim.
Since you will not be physically examined by a Contract Medical Consultant (CMC), obtaining your current medical records and ADLs or equivalent record from your physician is important in determining your rating. The lack of medical information, could potentially affect your impairment rating. Below is an example of the ADL information needed from your physician, as referenced in the AMA’s Guides, Table 1-2.
| Activity | Example |
|---|---|
| Self-care, personal hygiene | Urinating, defecating, brushing teeth, combing hair, bathing, dressing oneself, eating |
| Communication | Writing, typing, seeing, hearing, speaking |
| Physical activity | Standing, sitting, reclining, walking, climbing stairs |
| Sensory function | Hearing, seeing, tactile feeling, tasting, smelling |
| Nonspecialized hand activities | Grasping, lifting, tactile discrimination |
| Travel | Riding, driving, flying |
| Sexual function | Orgasm, ejaculation, lubrication, erection |
| Sleep | Restful, nocturnal sleep pattern |
| Activities of Daily Living Questionnaire | Name: |
| Case ID #: |
| Accepted Conditions | ICD-9/10 Code | Condition @ MMI[1] |
|---|---|---|
| Yes No | ||
| Yes No | ||
| Yes No |
| See attached if more than 3 conditions |
| Rating Scale (Each criteria is graded in level of dependence) 1 – Performs independently without reminder or assistance 2 – Performs with assistance or reminders 3 – Unable to perform on own, even if assisted |
| Is the claimant terminal? YES NO If YES, estimated timeframe: _____________________________________________ |
Since the employee will not be physically evaluated for impairment by a Department of Labor physician, the following information regarding the employee’s Activities of Daily Living (ADL) or equivalent information is required. Rate the activity based only on limitations caused or contributed to by the accepted condition(s). Address all items using the above rating scale to determine the person’s ability to perform the activity.
| Self-Care / Personal Hygiene | Rating | Additional comments concerning these activities | ||
|---|---|---|---|---|
| Dressing/undressing oneself | ||||
| Eating | ||||
| Meal preparation | ||||
| Taking or managing medicine | ||||
| Toileting - getting to and on/off toilet | ||||
| Toileting - keeping self-clean and dry | ||||
| Toileting - arranging clothes | ||||
| Bladder/Bowel control | ||||
| Brushing teeth | ||||
| Combing/brushing hair | ||||
| Bathing | ||||
| Light housekeeping |
| Communication | Rating | Additional comments concerning these activities | ||
|---|---|---|---|---|
| Writing | ||||
| Typing | ||||
| Seeing | ||||
| Hearing | ||||
| Speaking |
| Physical Activity | Rating | Additional comments concerning these activities | ||
|---|---|---|---|---|
| Standing | ||||
| Sitting | ||||
| Reclining | ||||
| Walking | ||||
| Climbing Stairs |
| Sensory Function | Rating | Additional comments concerning these activities | ||
|---|---|---|---|---|
| Standing | ||||
| Sitting | ||||
| Reclining | ||||
| Walking | ||||
| Climbing Stairs |
| Other: Non-specialized hand activities | Rating | Additional comments concerning these activities | ||
|---|---|---|---|---|
| Grasping | ||||
| Lifting | ||||
| Pulling/Pushing | ||||
| Reaching up, down, out | ||||
| Tactile Discrimination |
| Travel | Rating | Additional comments concerning these activities | ||
|---|---|---|---|---|
| Riding | ||||
| Driving | ||||
| Flying | ||||
| Arranging travel for selft |
| Transferring In and Out of: | Rating | Additional comments concerning these activities | ||
|---|---|---|---|---|
| Bed | ||||
| Tub/Shower | ||||
| Chair/Sofa | ||||
| Vehicles |
| Sexual Function | Rating | Additional comments concerning these activities | ||
|---|---|---|---|---|
| Orgasm | ||||
| Ejaculation | ||||
| Lubrication | ||||
| Erection |
| Sleep | Rating | Additional comments concerning these activities | ||
|---|---|---|---|---|
| Restful | ||||
| Nocturnal Sleep Pattern |
| Provide any additional comments to explain what this person can or cannot do in their daily life (if additional space is needed, please provide a typed narrative report and attach it to this questionnaire): |
The information listed above is complete and accurate to the best of my knowledge:
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| Activities of Daily Living | Name: |
| Supplementary ADL Specific to: Breast Cancer | Case ID #: |
Is the patient at MMI for breast cancer and if so what date? MMI Yes No Date:
| 1. Was removal of part or all of one or both breast required? If so, describe. |
| 2. Is there resulting lymphedema in the affected arms? If so, describe severity. Is it partially or completely controlled with stockings? |
| 3. Is there a resulting decrease of motion in affected extremities? If so, detail range of motion for those joints. |
| 4. Is there any decrease in strength in the upper extremities? If so, describe on a scale of 0-5 with mention of involved motor nerves. |
| 5. Is there decreased sensation in the affected extremities? If so, describe with mention of which sensory nerves. |
| 6. Is there any intermittent or continuous pain of the chest wall? If so, describe. |
| 7. Has there been metastasis? If so, describe. |
| Additional Comments: |
| Activities of Daily Living | Name: |
| Supplementary ADL Specific to: Skin Cancer | Case ID #: |
Is the patient at MMI for skin cancer and if so what date? MMI Yes No Date:
| 1. Is the claimant limited to sun exposure? If so, describe. |
| 2. Does the claimant have a significant deformity from the skin cancer affecting interpersonal relationships? If so, please describe. |
| 3. Does the claimant have a deformity or scarring that limits range of motion of any joints? If so, please state joint and indicate range of motion. |
| 4. Does the claimant require use of a prescriptive drug for the treatment of skin cancer, either intermittently or continuously? If so, please describe. |
| 5. Does the claimant’s skin cancer limit any ADL other than sun exposure? If so, please describe. |
| 1. Has there been metastasis? If so, please describe. |
| Additional Comments: |
[1] Condition has reached maximum medical improvement (MMI) i.e. well-stabilized and unlikely to improve with medical treatment or not required if an illness is in a terminal stage.