Rev: 3.44.

0
STATE OF HAWAII Case Number
DEPARTMENT OF LABOR & INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION 2202312345
Date Received
WC-2 PHYSICIAN'S REPORT 12/31/2023
Type of Report

FIRST FIRST & FINAL FINAL INTERIM CONSULTING

PATIENT INFORMATION - SECTION 1
Patient Last Name Patient First Name Patient M.I. Patient Suffix

Holland Tom A Jr.

Address City State Zip Code

711 Kapiolani Blvd Ste 500 Honolulu HI 968135255

Identification Type Identification Number Email Address Phone Number

SSN PASSPORT *****1234 tomholland123@email.com (717) 123-6758

Date of Injury/Illness Date of First Treatment If Patient Deceased, Give Date

12/12/2023 12/12/2023 12/13/2023

EMPLOYER – SECTION 2
Registered Employer Name DBA

DataHouse Consulting, Inc. DataHouse

Address City State Zip Code

711 Kapiolani Blvd Ste 500 Honolulu HI 968135255

Employer Point of Contact (POC) Email Address Phone Number

Anne Hathaway annehathaway@email.com (717) 123-6758

WC INSURANCE CARRIER AND ADJUSTER - SECTION 3
Carrier ID Carrier Carrier Case Number

1234 ABC Insurance Carrier AA202345

Address City State Zip Code

711 Kapiolani Honolulu HI 968135255

Adjuster ID Name of Adjusting Company Adjuster Name

1235 ABC Adjusting Service Company Anne Hathaway

Email Address Phone Number

annehathaway@email.com (717) 857-2384

PHYSICIAN INFORMATION - SECTION 4
Name of Physician Federal Employer ID Number (FEIN) Physician License #

ABC Hawaii Medical Center 123456789 ABC12678

Address City State Zip Code

711 Kapiolani Blvd Ste 500 Honolulu HI 968135255

Email Address Phone Number

annehathaway@email.com (717) 857-2384

1. Are you the attending 2. Has the patient been 3. Is there a possibility of 4. Do you think physical 5. Do you think medical
physician? burned? other disfigurement? rehabilitation will be necessary? rehabilitation will be necessary?

NO YES NO YES NO YES NO YES NO YES

A. State in patient's own words where and how the injury/illness occurred

This is a long text area describing fully the events that resulted in
injury/illness or occupational disease in patient’s own words.
B. Give accurate description and extent of injury/illness - Specify ALL parts of the body involved and state objective findings

This is a long text area that gives accurate description and extent of the
injury/illness - specify all parts of the body involved and state objective
findings.

EQUAL OPPORTUNITY EMPLOYER/PROGRAM

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TDD/TTY Dial 711 then ask for (808) 586-9161.
Page 1 of 4
 Rev: 3.44.0
Multiple Body Parts?

NO YES
# TYPE SIDE OF INJURY/ILLNESS PART OF BODY OTHER DISFIGUREMENT BURN
1 Injury LEFT Shoulder NO NO
RIGHT YES YES
2 Illness/Condition LEFT Depression - NO NO
RIGHT Suicide YES YES
3 Injury LEFT Other Teeth NO NO
RIGHT YES YES
4 Illness/Condition LEFT Disease - NO NO
RIGHT Cancer YES YES
5 Illness/Condition LEFT Difficulty NO NO
RIGHT Breathing YES YES
C. Is Injury/Illness State contributing causes
mentioned above the only
case of patient's condition? This is a long text area. If “C. Is Injury/Illness mentioned
NO YES above the only case of patient's condition?” is Yes, state
contributing causes.
D. Who engaged your services?

This is a long text area, this is a long text area, this is a long text area,
this is a long text area, this is a long text area, this is a long text area,
this is a long text area, this is a long text area, this is a long text area.
E. Is further treatment How long?
required?
This is a long text area. If "E. Is further treatment required?"
NO YES is Yes, state how long.
F. Were X-Rays taken? If yes, by whom? Date(s)

NO YES This is a long text area. If " F. Were X-Rays 13

taken?" is Yes, state by whom.
G. X-Ray diagnosis

This is a long text area, this is a long text area, this is a long text area,
this is a long text area, this is a long text area, this is a long text area,
this is a long text area, this is a long text area, this is a long text area.
H. Was patient treated by If yes, by whom? Date(s)
anyone else?
This is a long text area. If " H. Was patient 13
NO YES treated by anyone else?" is Yes, state by whom.
Was patient hospitalized? Date of Admission Date of Discharge Name of Hospital

NO YES 12/12/2023 12/12/2023 Hawaii Hospital

Address City State Zip Code

711 Kapiolani Blvd Ste 500 Honolulu HI 968135255

I. Describe subsequent treatment to be provided by you

This is a long text area, this is a long text area, this is a long text area,
this is a long text area, this is a long text area, this is a long text area,
this is a long text area, this is a long text area, this is a long text area.
Did I/I result in disability for work? Date Disability Began Patient - Please select Type of Work

NO YES 12/12/2023 Was able to resume work Regular Work

Will be able to resume work Light Work
Date Resume(d) Work On Patient Stopped Treatment Without Orders On Patient Discharged As Cured On

12/21/2023 12/21/2023 12/21/2023

EQUAL OPPORTUNITY EMPLOYER/PROGRAM

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Page 2 of 4

J. Does patient have any
defect or disfigurement?
NO YES
K. Final Diagnosis
Rev: 3.44.0
Describe below. Include scars, discolorations, deformities, etc.
This is a long text area. If " J. Does patient have any defect or
disfigurement?" is Yes, describe.

This is a long text area, this is a long text area, this is a long text area,
this is a long text area, this is a long text area, this is a long text area,
this is a long text area, this is a long text area, this is a long text area.
SIGNATURE – SECTION 5
I declare under penalty of law that all the information provided herein is true and correct to the best of my knowledge and belief.
Signature Date Email Address

Tom Holland 12/12/2024 tomholland123@email.com

EQUAL OPPORTUNITY EMPLOYER/PROGRAM

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TDD/TTY Dial 711 then ask for (808) 586-9161.
Page 3 of 4
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