1. Diagnosis

2. Within reasonable medical probability, what was the proximate cause of the injury diagnosed above?

3. Is the condition directly related to the incident in question?  Please explain why or why not.

4. Did the injury precipitate, aggravate, or accelerate a pre-existing or deteriorating condition beyond normal progression?  If so, please explain.

5. Did the incident cause a temporary aggravation of a pre-existing condition?  If so, please explain.

6. Were the symptoms complained of a mere manifestation of a pre-existing deteriorating condition?  If so, please explain.

7. Was an appreciable period of workplace exposure the sole cause or at least a material contributory, causative factor in the conditions onset or progression?

8. Is the "natural aging process" or some other injury the proximate cause of the impairment/disability?  Please explain.

9.  Did the patient experience an active medical condition prior to the injury?

10. Is further medical treatment needed?  If so, please explain.

11. Has all treatment been related to injuries sustained on the date of the accident?  Please be as specific as possible, and please explain why or why not.

12. Of the treatment related to the injury, what appears appropriate and necessary?  Please be as specific as possible, and please explain why or why not.

13. Has the claimant reached a maximum medical improvement as described in the 5th Edition of the AMA Guides?

14. Has the claimant sustained a permanent harmful change in his/her condition?  If so, please calculate via the 5th Edition AMA Guides.

15. Do you feel the claimant should have any restrictions?  If so, please specify what they are, how long they should remain in effect, and if they are related to the incident in question.

16. Has the claimant described the physical requirements of his job performance at the time of the injury?

17. Does the claimant retain the physical capabilities and strength to return to the job he/she performed at the time of the injury?