Initial Assessment Worksheet

Claimant: LarryTurner Claim No: Claim Number

DOB: 11/06/1974 Date of Referral: 11/01/2023

Date of Injury: October/2021 Injury: An excruciating pain

after a pop in the
shoulder

Pre Injury Wage - Date of Assessment: 11/01/2023

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 ..Larry turner had been to the bay with his full energy and zest. Well, the weather was sunny

and beautiful at the power lines where Larry would work. Subsequently, Larry pulled a lever and he heard a pop

sound from his arm. He became temporarily careless but the consistent pain made him worried. As the day

progressed, the pain just got worse and worse and worse and it didn’t feel

right. ...................................................................................................................... .................................................

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Previous treatment and medical investigations

Date Treatment or Medical Outcome and Findings
Appointment

15/10/2021 surgery Right shoulder Arthroscopy

X-ray Impingement syndrome

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: Larry is anxious about happening this again.
Current Medical Certification
Name of Medical Practitioner: Jimmy

Certificate Period: From:01/10/2021

To: 30/03/2023

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Current Symptoms ..........Larry rates 2/10 and 4/10 on his pain status. Moreover, he feels pains and finds it

difficult to carry boxes or lifting

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Visual Analogue Scale

No pain |_____2_____________________________________________| Worst possible pain (Ambulance

required) 0 5 10

Self-reported functional tolerances

Sitting: Full day

Standing: 2-3 hours

Walking: 5-7 km

Squatting no

Kneeling no

Lifting: Floor to waist yes

Waist to waist yes

Waist to shoulder yes

Waist to overhead yes

Carrying • Bilateral: / Distance: Up to a few meters

• Unilateral: / Distance: Up to a few km
Active Range of no
Movement:

Primary triggers What makes the symptoms worse?

for the 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

Junior teller •admin type 20 years

tasks, counting money, inputting data in the
computer and spreadsheets, customer service

Excel masterclasses, •Banking 12 years

TAFE

Forklift licence, TAFE •Banking 12 years

Landscaping, TAFE •Banking 12 years

Plan:

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