[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-170960-105":53,"doc-detail-170960-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","independent-medical-exam-form","Independent Medical Exam - Form","","Independent Medical Exam form template for documenting identifying details, injury history, chief complaints, current symptoms, occupational history, and relevant medical and socioeconomic background. Includes structured review of systems, record review, and a physical examination section with exam findings. Provides diagnostic studies and pain status inventories, followed by conclusions on accepted conditions, work-related diagnoses, prognosis, physical restrictions, job analysis review, recommendations, and an impairment rating report with maximum medical improvement, rationale, and supporting details.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/independent-medical-exam-form/170960/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/independent-medical-exam-form/170960.png","ImageObject",442,249,{"name":88,"@type":89},"wps_ap_test_251126_0180","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-10-23","2026-09-01",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information must be completed in the Identifying Information and Introduction sections?","Question",{"text":109,"@type":110},"The form collects identifying information and an introduction, then records history from the worker including chief complaints, history of present injury, current symptoms, occupational history, current work status, and past medical history.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What sections cover the medical evaluation and diagnostic work?",{"text":114,"@type":110},"The document includes a review of systems and record review, a physical examination with exam findings, and a diagnostic studies section with pain status inventories.",{"name":116,"@type":107,"acceptedAnswer":117},"How are conclusions and impairment rating handled?",{"text":118,"@type":110},"Conclusions document accepted conditions, diagnoses and work-relatedness, prognosis, physical restrictions, job analysis review, recommendations, and any unrelated findings. The impairment rating report records maximum medical improvement, physical exam details, diagnostic tests, rating, and rationale.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},170960,1788278299,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":126,"read_time":9},8796095027276,"https://avatar.qwps.com/avatar/d3BzX2FwX3Rlc3RfMjUxMTI2XzAxODA=","Independent Medical Exam\nIdentifying Information\nIntroduction\n\u0013 FORMTEXT \u0014________________________________________________________________________________\u0015\nHistory from worker\nChief complaints:\n\u0013 FORMTEXT \u0014_________________________________________________________________________\u0015\nHistory of present injury:\n\u0013 FORMTEXT \u0014_________________________________________________________________________\u0015\nCurrent symptoms:\n\u0013 FORMTEXT \u0014_________________________________________________________________________\u0015\nOccupational history:\n\u0013 FORMTEXT \u0014_________________________________________________________________________\u0015\nCurrent work status:\n\u0013 FORMTEXT \u0014_________________________________________________________________________\u0015\nPast medical history:\nFamily history:\n\u0013 FORMTEXT \u0014_________________________________________________________________________\u0015\nSocioeconomic history:\nReview of systems:\n\u0013 FORMTEXT \u0014_________________________________________________________________________\u0015\nRECORD REVIEW\n\u0013 FORMTEXT \u0014________________________________________________________________________________\u0015\nPHYSICAL EXAMINATION\nEXAM FINDINGS:\n\u0013 FORMTEXT \u0014________________________________________________________________________________\u0015\nDIAGNOSTIC STUDIES\n\u0013 FORMTEXT \u0014________________________________________________________________________________\u0015\nPain Status Inventories\n\u0013 FORMTEXT \u0014________________________________________________________________________________\u0015\nCONCLUSIONS\nAccepted conditions (as stated on the assignment letter from the claim manager):\n\u0013 FORMTEXT \u0014____________________________________________\u0015\nDiagnoses and assessment of work-relatedness:\nDiagnoses:\n\u0013 FORMTEXT \u0014____________________________________________\u0015\nPre-existing conditions:\n\u0013 FORMTEXT \u0014____________________________________________\u0015\nConditions acquired after the industrial injury or exposure:\n\u0013 FORMTEXT \u0014____________________________________________\u0015\nDiscussion and assessment of work-relatedness:\n\u0013 FORMTEXT \u0014__________________________________________________________________\u0015\nPrognosis:\n\u0013 FORMTEXT \u0014__________________________________________________________________\u0015\nPhysical Restrictions:\n\u0013 FORMTEXT \u0014__________________________________________________________________\u0015\nReview of Job Analyses\n\u0013 FORMTEXT \u0014__________________________________________________________________\u0015\nRecommendations:\nDiagnostic:\n\u0013 FORMTEXT \u0014__________________________________________________________________\u0015\nTherapeutic:\n\u0013 FORMTEXT \u0014__________________________________________________________________\u0015\nFollow-up care:\n\u0013 FORMTEXT \u0014__________________________________________________________________\u0015\nFindings unrelated to the accepted condition:\n\u0013 FORMTEXT \u0014__________________________________________________________________\u0015\nImpairment Rating Report\nMaximum Medical Improvement:\n\u0013 FORMTEXT \u0014__________________________________________________________________\u0015\nPhysical exam:\n\u0013 FORMTEXT \u0014__________________________________________________________________\u0015\nDiagnostic tests:\n\u0013 FORMTEXT \u0014__________________________________________________________________\u0015\nRating:\n\u0013 FORMTEXT \u0014__________________________________________________________________\u0015\nRationale:\n\u0013 FORMTEXT \u0014__________________________________________________________________\u0015\nANSWERS TO SPECIFIC QUESTIONS FROM THE CLAIM MANAGER\n\u0013 FORMTEXT \u0014________________________________________________________________________________\u0015","cbCaitXeq3B75iSa","https://ap.wps.com/l/cbCaitXeq3B75iSa","docx",23763,"English","# Identifying Information\n## Introduction\n## History from Worker\n## Review of Systems and Record Review\n# Physical Examination\n## Exam Findings\n# Diagnostic Studies\n## Pain Status Inventories\n# Conclusions\n## Accepted Conditions and Work-Relatedness\n## Prognosis and Physical Restrictions\n## Recommendations and Follow-up Care\n## Findings Unrelated to Accepted Condition\n# Impairment Rating Report\n## Maximum Medical Improvement and Rating\n## Rationale\n# Answers to Specific Questions from the Claim Manager","[{\"question\":\"What information must be completed in the Identifying Information and Introduction sections?\",\"answer\":\"The form collects identifying information and an introduction, then records history from the worker including chief complaints, history of present injury, current symptoms, occupational history, current work status, and past medical history.\"},{\"question\":\"What sections cover the medical evaluation and diagnostic work?\",\"answer\":\"The document includes a review of systems and record review, a physical examination with exam findings, and a diagnostic studies section with pain status inventories.\"},{\"question\":\"How are conclusions and impairment rating handled?\",\"answer\":\"Conclusions document accepted conditions, diagnoses and work-relatedness, prognosis, physical restrictions, job analysis review, recommendations, and any unrelated findings. The impairment rating report records maximum medical improvement, physical exam details, diagnostic tests, rating, and rationale.\"}]","Independent Medical Exam - Form | DOCX"]