MODIFIED SUMMARY OF MEDICAL RECORD

Patient Name: Federico Martinez Cabo

SSN: N/A; DOB:\bl4lqb; Date of tnjury: Decem ber 27 20,tg
Employer: RRHH Snoivbasin

1. Description of industrial injury:

2' Please list the patient's medical problem(s) which, in your opinion, likely were caused,
aggravated, lit up or accelerated by the induskial
accident or exposure.

3. The following reasonable and necessary medical care is needed as a result of

the industrial injury: Follow up.rre I X Medication I
Physical therapy XDiagnostic tests !
lnjections I
possibte surgery Srrgeryn wtedicatdevicetr prosthesis. tr
Please explain as necessary:

4. Ability to work:
E The patient is permanently unable to work as of _/_/_, OR
The patient is temporarily unable to work as of _/_/_, OR
The patient is able to work but with the following duty and/or time restrictions
WorkRestictions
as of _/_/_

5. The patient reached maximum medical improvement (MMl) (MMl further i mprovement
= in patient's medical condition is no longer
expected) as of: OR patient is not at MMt yet.

(complete if at MMI) The patient did not return to pre-accident baseline

and the whole person impairment rating from the industrial injury
(in accordance with the AMA and Utah 2006 lmpairment Rating
Guides) is: OR, I I recommend a rating be given, but do
not issue these myself (additional comments):
--%
(complete if NOT yet at MMI) I expect the patient to reach MMI on the
following date:
The patient did not return to pre-accident baseline and the estimated whole person
_/_/
impairrnent rating from the industrial injury (in
accordance with the AMA and / or the Utah 2006 lmpairment Rating Guides)
given, but do not issue these myself (additional comments):
will likely be _% OR, I recommend a rating be

6. Pre-existing condition(s):
tr tn my opinion there were no contributory pre-existing condition(s), OR
The patient had the fotlowing pre-existin g condition(s):
AND
this pre-existing condition likely DID Nor contribute to the present industrial
injury, oR
this pre-existing condition likety DtD contribute to the present industrial injury.

! rne current industrial injury is likely a permanent aggravation of the pre-existing

medical condition and/or impairment.
I rnir condition is likely only a temporary aggravation of the preexisting condition

DATED this _ day of

Physician's signature
Physician's street address

Physician's name (please print)

Physician's city, state, zip

Physician's specialty
Physician's telephone number